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January,   1869. 
I. 

On  Chronic  Eronchitis, 

Especially  as  Connected  with  Gout,  Emphysema,  and  Diseases  of  the 
Heart.  Being  Clinical  Lectures  delivered  at  the  Middlesex  Hospital, 
by  E.  Headlam  Greenhow,  M.D.,  Fellow  of  the  Royal  College  of 
Physicians,  Consulting  Physician  to  the  Western  General  Dispensary, 
&c.,  &c. 

One  volume.      Octavo.      Price,  $2.25. 
Tlie  jiurpose  of  this  volume  is  to  (demonstrate  the  frequently  constitutional  character 
of  Chronic  Broncliitis,  and  its  intimate  association  with  many  other  diseases,  in  the  re- 
lation eitiier  of  cause  or  of  consequence. 

In  the  earlier  lectures  the  author  has  endeavored  to  show,  from  the  results  of  a  lars;e 
suialysis  of  cases,  and  also  from  the  history  of  many  individual  cases,  in  how  small 
;i  jjroportion  of  bronchitic  patients  the  liability  to  suffer  from  Chronic  Bronchitis  can 
be  traced  exclusively  to  catarrh,  and  in  how  large  a  proportion  it  can  be  referred  to  ca- 
tarrh only  in  connection  with  one  of  three  internal  jiredisposing  causes  ;  namely,  long- 
standing mechanical  irritation  of  the  bronchial  membrane  5  some  form  of  Dvscrasia  ■ 
or  previous  illness  of  some  other  kind.  The  Gouty  Dyscrasia  is  shown  to  be,  of  all  others, 
perhaps  the  most  fruitful  source  of  Chronic  Bronchitis.  The  fifth  and  sixth  lectures 
•deal  with  the  subject  of  Pulmonary  Emphysema;  showing  from  an  analysis  of  cases, 
and  also  from  detailed  cases,  that  Emphysema  is  frequently  hereditary;  that  it  is  fre- 
quently tbund  in  connection  with  the  Gouty  Dyscrasia ;  and,  lastly,  that  it  is  not  un- 
frequently  developed,  in  these  circumstances,  previous  to  the  existence  of  Chronic  Bron- 
chitis. These  facts,  in  the  Author's  opinion,  prove  the  mainly  constitutional  character 
of  Pulmonary  Emphysema,  and  lead  to  the  further  conclusion  that  the  degeneration  of 
the  tissue  of  the  lungs  which  predisposes  them  to  yield  to  mechanical  causes  of  disten- 
sion, in  coughing  or  otherwise,  is  often  a  result  of  the  Gouty  Dyscrasia.  In  the  seventh 
and. eighth  lectures,  the  relations  between  Bronchitis  and  Diseases  of  the  Heart  are  fullv 
considered.  Bronchitis  is  shown  to  be  a  frequent  sequel  to  diseases  of  the  left  side  of 
the  heart;  whilst  it  is,  on  the  other  hand,  itself  a  direct  cause  of  disease  of  the  rii'ht 
side  of  the  heart. 

The  practical  conclusion  suggested  by  the  work  is  that  the  first  step  towards  the  suc- 
cessful treatmant  of  Chronic  Bronchitis  must  be  the  discovery,  and,  in  so  far  as  may  be 
possible,  the  i-emoval,  or  alleviation,  of  the  internal  condition  which,  in  so  manv  cases 
is  the  remote  cause  of  the  patient's  ailment. 

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3- 

A  Treatise  on  the  Diseases  of  the  Eye, 

Illustrated  by  Ophthalmoscopic  Plates  done  in  Chromo-Lithography, 
and  engravings  on  wood.  By  J.  Scelberg  Wells,  Professor  of 
Ophthalmology  in  King's  College,  London  ;  Ophthalmic  Surgeon  to 
King's  College  Hospital,  and  Assistant  Surgeon  to  the  Royal  London 
Ophthalmic  Hospital,  &c.,  &c. 
One  volume,  octavo,  bevelled  cloth.      Price,  $9.00. 

The  great  reputation  of  the  Author  of  this  volume,  and  his  long  experience  in  the 
treatment  of  Diseases  of  the  Eye,  together  with  the  unusual  facilities  possessed  by  him, 
as  Professor  of  Ophthalmology,  and  as  Surgeon  to  King's  College,  and  the  Royal  Lon- 
don Ophthalmic  Hospital,  has  enabled  him  to  make  it  the  most  complete  and  compre- 
hensive work  on  the  subject  in  the  English  Language. 

It  embodies  all  the  most  recent  views  in  Ophthalmology,  as  well  as  the  newest  opera- 
tions upon  the  eye,  fully  illustrated.  The  Oph'Jhalmoscope  and  its  Use  in  the 
internal  diseases  of  the  eye,  receives,  also,  the  fullest  consideration,  and  is  illustrated 
by  beautifully  colored  plates. 

4. 

A  History  of  the  Medical  Department  of  the  University  of 

Pennsylvania,  from  its  foundation  in  1765,  with   illustrative   sketches  ot 
Deceased   Professors,  &c.,  &c.      By  Joseph    Carson,  M.D.,    Pro- 
fessor of  Materia  Medica  and   Pharmacy  in  that  Institution. 
One  volume,  octavo.      Price,  $3.00. 

5- 

Kidney  Diseases,  Urinary  Deposits,  and  Calculous  Disorders, 

Their  nature  and  treatment,  containing  seventy  plates  and  tables  for  the 
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Octavo,  printed  on  tinted  paper.      Price,  $12.00, 

ALSO, 

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Fourth  Edition.      Over  400  Illustrations. 
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A  TREATISE 


DISEASES  or  THE  EYE. 


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A    TEEATI8E 


DISEASES  OF  THE  EYE 


J.    SOELBEEG    WELLS, 

Professor  of  Ophthalmology  in  King's  College,  London,  Ophthalmic  Surgeon  ■ 

King's  College  Hospital,  and  Assistant  Surgeon  to  the  Royal 

London  Ophthalmic  Hospital,  Moorfields. 


PHILADELPHIA  : 
LINDSAY    AND     B  L  A  K I S  T  0  N 


MUCCqLXIX. 

[The  right  nf  Traiislalion  is  reserved.] 


LONDON : 
HARBISON   AND   SONS,   PKINTEES  IN   OEDINAEY   TO   HEB  MAJKSTT,   ST.   MAETIN's  LANK. 


bUCJ 


PROFESSOR  ALBRECHT  VON  GRAEFE, 


THIS   WOEK   IS   DEDICATED, 


SLIGHT  TRIBUTE   OF  ADMIEATIOX   FOR   HIS   EMINENT  MERITS   IN   THE 
ADVANCEMENT  OF  OPHTHALMOLOGY, 


GRATITUDE   FOR   HIS   UNYARYINO   KINDNESS   AND   FRIENDSHIP, 


THE   AUTHOR. 


P  E  E  F  A  C  E. 


Within  the  last  few  years  the  want  has  often  been  expressed 
of  an  EngHsh  treatise  on  the  diseases  of  the  eye,  which  should 
embrace  the  modern  doctrines  and  practice  of  the  British  and 
Foreign  Schools  of  Ophthalmology,  and  should  thus  enable 
the  practitioner  and  student  to  keep  up  ^\ath  the  knowledge 
and  opinions  of  the  present  day. 

I  now  venture  to  lay  before  the  profession  a  work  which  I 
trust  may  be  deemed,  to  a  certain  extent,  worthy  to  meet  this 
desideratum.  Whilst  I  have  endeavoured  to  enter  fully  mto 
all  the  most  important  advances  which  have  been  lately  made 
in  OiDhthalmic  science,  I  have  not  contented  myself  with 
simply  recording  the  views  of  others,  but  have  sought  in 
most  instances  to  make  myself  practically  conversant  with 
them,  so  that  I  might  be  able,  from  my  own  experience,  to 
form  an  iadependent  aiid  unbiassed  opinion  as  to  their  rela- 
tive value.  The  vast  and  peculiarly  favourable  opportimities 
which  I  have  had  at  Moorhelds  of  studying  all  phases  and 
kinds  of  eye-disease,  as  well  as  the  great  benefit  which  I  have 
enjoyed  of  witnessing  the  j^ractice  and  operations  of  my  col- 
leagues, have  most  materially  assisted  me  in  the  possibility  of 
doing  this. 

In  preparing  this  work,  I  have  steadily  kept  one  purpose 
in  view,  viz.,  to  make  it  as  practical  and  comprehensive  as 
possible,  and  I  have,  therefore,  entered  at  length  into  an  ex^ 
planation  of  those  subjects  which  I  have  fomid  to  be  particu- 
larly difficult  to  the  beginner.  I  have,  on  purpose,  occasionally 
repeated  important  points  in  diagnosis  and  treatment,  in  order 
to  render  each  article,  to  a  certain  extent,  complete  in  itself, 


viil  PREFACE. 

SO  as  to  obviate  the  necessity  of  the  reader  having  constantly 
to  refer  to  other  portions  of  the  book  for  explanation  or  in- 
formation. Moreover,  I  have  thonght  that  this  would  prove 
of  great  convenience  to  those  who  may  desire  to  consult  and 
study  certain  subjects,  without  being  obliged  to  peruse  the 
greater  portion  of  the  book. 

The  subjects  of  "  Injuries  to  the  Eye,"  and  of  "  Congenital 
Malformations  of  the  Eye,"  have  assumed  such  considerable 
dimensions,  that  I  have  been  obliged  to  treat  of  them  somewhat 
briefly,  and  would,  therefore,  refer  the  reader,  who  seeks  for 
fuller  information,  to  special  treatises  upon  these  affections. 
Of  these,  I  would  particularly  recommend  the  following  excel- 
lent works : — "  Injuries  of  the  Eye,  Orbit,  and  Eyelids,"  by 
Mr.  George  Lawson;  "  Verletzungen  des  Auges,"  by  Drs. 
Zander  and  Geissler  ;  and  the  "  Malformations  and  Congenital 
Diseases  of  the  Organs  of  Sight,"  by  Sir  William  Wilde. 

My  best  and  warmest  thanks  are  due  to  my  colleagues  at 
the  Royal  Loudon  Ophthalmic  Hospital,  Moorfields,  and  more 
especially  to  Mr.  Bowman,  for  their  constant  kindness  in  per- 
mitting me  to  have  free  access  to  their  cases,  and  for  affording 
me  much  valuable  information  and  advice  upon  all  suljjects 
connected  with  Ophthalmology. 

Owing  to  the  great  liberality  of  my  friend  Dr.  Liebreich, 
and  of  his  publisher,  Mr.  Hirschwald  of  Berlin,  I  have  been 
able  to  illustrate  this  work  with  16  excellent  coloured  oph- 
thalmoscopic figures,  which  are  copies  of  some  of  the  plates 
of  Liebreich's  admirable  "  Atlas  D'Ophthalmoscopie." 


As  very  fi-equent  reference  is  made  to  certain  Ophthalmic 
periodicals,  I  have  used  the  following  abbreviations : — 

R.  L.  0.  II.  Rep.  signifies  "  Royal  London  Ophthalmic 
Hospital  Reports,"  edited  by  Messrs.  AVordsworth  and  Hutchin- 
son (Churchill). 

A.  f.  0.  signifies  "  Arcliiv  filr  Ophthalmologie,"  edited  by 
Profs.  Arlt,  Donders,  and  Von  Graefe  (Peters,  Berlin). 

Kl.  Monalshl.  signifies  "  Klinische  Monatsblilttcr  der  Augen- 
heilkunde,"  edited  by  Prof.  Zehender  (Enke,  Erlangen). 


PREFACE.  ix 

The  following  symbols  are  also  fi-equently  employed  in  the 
com-se  of  the  work: — A,  means  range  of  accommodation;  r, 
punctmn  remotissimmn  (far  point);  j?,  pmictum  proximum 
(near  point);  co  (=0),  infinite  distance;  ',  foot,  ",  inch,  '", 
line. 

The  test  types  of  Jaeger  may  be  obtained  from  the  Secre- 
tary of  the  Royal  Loudon  Ophthalmic  Hospital,  Moorfields ; 
and  those  of  Snellen  from  Messrs.  Williams  and  Norgate, 
Henrietta  Street,  Covent  Garden. 

16,  Savile  Eow, 

December,  1868. 


CONTENTS. 


Introduction. 


PAGE 


Eversion  of  the  Upper  Eyelid — The  mode  of  ascertaining  the  degree  of 
Intra-oeidar  Tension — The  examination  of  the  Acuteness  of  Vision — 
Mode  of  examining  the  Field  of  Vision — Diplopia — The  Compress 
Bandage — The  Artificial  Leech — The  Eye-donche         . .  . .  . .        1-14 

Chaptee   I. 

DISEASES  OF  THE  CONJUNCTIVA. 

Hyperaemia  of  the  Conjunctiva — Catarrhal  Ophthalmia — Purulent  Ophthal- 
mia— GonoiThoeal  Ophthalmia — Ophthalmia  Neonatarum — Diph- 
theritic Conjunctivitis — Grranular  Ophthalmia — Acute  Grranidar 
Ophthalmia — Chi'ouic  Granulations — Phlyctenidar  Ophthalmia — 
Exanthematous  Ophthalmise — Xerophthalmia — Pterygium —  Symble- 
pharon — Anchyloblepharon — Injm-ies  of  the  Conjunctiva — Timiours 
of  the  Coniunctiva,  etc.      . .  . .  . .  . .  . .  . .  . .      15-88 

Chapter  II. 

DISEASES  OF  THE  COENEA. 

Pannus — Phlyctenular  Comeitis — Fascicular  Corneitis — Suppiu-ative  Cor- 
neitis — Non-Inflammatory  Suppm-ative  Corneitis — Ulcers  of  the 
Cornea — Diffuse  Corneitis — Opacities  of  the  Cornea — Ai-cus  Seudis — 
Conical  Cornea — Kerato-globus — Staphyloma  of  the  Cornea  and  Ii'is 
— Injuries  and  woimds  of  the  Cornea      . .  . .  . .  . .  . .      8Q-I43 

Chapter  III. 

DISEASES  OF  THE  IRIS. 

Hypersemia  of  the  Iris — luflanunation  of  the  Iris — Functional  Distui'b- 
ances  of  the  Iris — Tremulousness  of  the  Iris — Wounds,  etc.,  of  the 
Iris— Tumours  of  the  Iris — Congenital  Anomalies  of  the  Iris — Iri- 
dectomy— Iridodesis — Corelysis — Iridodialysis — Changes  in  the  con- 
tents, etc.,  of  the  Anterior  Chambei- — Irido-choroiditis — Sympathetic 
Ophthalmia 144-205 


xii  CONTENTS 

Chapter  IV. 
DISEASES  OF  THE  CILIARY  BODY  AND  SCLEROTIC. 

PAGE 
Inflammation  of  Ciliary  Body — Injuries  of  Ciliary  Region— Episcleritis — 

Anterior  Sclerotic  Staphyloma — Woimcls  and  lujiu'ies  of  the  Sclerotic  206-214 

Chapter  V. 
DISEASES  OF  THE  CRYSTALLINE  LENS. 

Cataract — Lamellar  Cataract—  Cortical  Cataract — Nuclear  Cataract — Trau- 
matic Cataract — Capsular  Cataract — Flap  Extraction — Removal  of  the 
Lens  in  its  Capside — Linear  Extraction — Scoop  Extraction — Von 
Grraefe's  Operation — Rcclination — Division  of  Cataract — Operations 
for  Lamellar  Cataract — Operations  for  Traimiatic  Cataract — Removal 
of  Cataract  by  a  Suction  Instrument — Sperino's  Treatment  of 
Cataract  by  Paracentesis — Operations  for  Capsular  Cataract — Disloca- 
tion of  the  Lens 215-282 

Chaptee  VI. 
THE  USE  OF  THE  OPHTHALMOSCOPE. 

Theory  of  the  use  of  the  Ophthahuoscope — Ophthalmoscope  of  Liebreich, 
Coccius,  and  Zehender — Fixed  Ophthalmoscope  of  Liebreich,  and  of 
Smith  and  Beck — Binocular  Ophthalmoscope  of  Giraud-Teulon — 
Aut-ophthalmoscope — The  Examination  with  the  Ophthalmoscope — 
The  Examination  of  the  Actual  Inverted  Image — The  Examination  of 
the  Virtual  Erect  Image — The  Ophthalmoscopic  Appearances  of 
Healthy  Eyes — The  Optic  Disc — The  Oplithalmoscopic  Appearances 
of  Diseased  Eyes . .    282-312 

Chapter  VII. 

DISEASES  OF  THE  VITREOUS  HUMOUR. 

Inflammation  of  the  Vitreous  Humour — Opacities — Foreign  Bodies,  etc., 

in  tlie  Vitreous — Persistent  Hyaloid  Artery       . .  . .  . .  . .    313-326 

Chapter  VIII. 

DISEASES  OF  THE  RETINA. 

Hypersemia  of  the  Retina — Retinitis,  Idiopatliic  and  Parenchymatous — 
Retinitis  Albuminurica,  Leucsemica,  Syphilitica,  Apoplectica,  Pigmen- 
tosa— Detachment  of  the  Retina — Epilepsy  of  the  Retina — Ischa;mia 
Retinae — Embolism  of  the  Central  Artery  of  the  Retina — Ilyperses- 
thesia  of  the  Retina — Tumours  of  the  Retina — Atrophy  of  the  Retina  327-374 


CONTENTS.  xiii 


Chapter  IX. 
DISEASES  OF  THE  OPTIC  NEEVE. 

PAGE 

Inflammation  of  the  Optic  Nerve — Atrophy  of  the  Optic  Nerve — Excava- 
tion of  the  Optic  Nerve — Pigmentation  of  the  Optic  Nerve — Tumours 
of  the  Optic  Nerve — Opaque  Optic  Nerve  Fibres         . .  . .  . .    375-395 

Chapter  X. 
AMBLYOPIC  AFFECTIONS. 

Amaxu'osis — Amblyopia — Hemeralopia — Coloiu*   Blindness — Simulation    of 

Amaurosis    . .  . .  . .  . .  ....  . .  . .  . .    396-421 

Chapter  XI. 

DISEASES  OF  THE  CHOEOID. 

Hypersemia  of  the  Choroid — Disseminated  Choroiditis — Sclerotico- 
choroiditis  Posterior — Suppvirative  Choroiditis — Colloid  Disease  of  the 
Choroid — Tubercles  of  the  Choroid — Tumours  of  the  Choroid,  Sar- 
coma, Carcinoma — Formation  of  Bone — Coloboma  of  the  Choroid — 
Ruptm'e  of  the  Choroid — Haemorrhage  from  the  Choroid — Detach- 
ment of  the  Choroid  . .  . .  . .  . .  . .  . .  . .    422-455 


Chapter  XII. 

aLAUCOMA. 

Acute  Inflammatory  Glaiicoma — Chronic  Inflammatory  G-laucoma — Grlau- 
coma  Simplex — Secondary  Glaucoma — Ophthalmoscopic  Symptoms 
of  Glaucoma — The  Natiu-e  and  Causes  of  the  Glaucomatous  Process — 
Prognosis  of  Glaucoma,  etc.         . .  . .  , .  . .  , .  , .    456-487 


Chapter  XIII. 

THE  ANOMALIES  OP  EEFEACTION  AND  ACCOMMODATION  OF  THE 

EYE. 

The  Eefraetion  and  Accommodation  of  the  Eye — Optical  Lenses,  etc. — 
Mechanism  of  Accommodation — Negative  Accommodation — The  Eange 
of  Accommodation — Myopia — Presbyopia — Hypermetropia — Astig- 
matism— Aphakia — Paralysis,  Spasm,  and  Atony  of  the  Ciliary  Muscle 
— Spectacles — Difference  in  the  Eefraetion  of  the  two  Eyes   . .  . .   488-547 


Xir  CONTENTS. 

Chapter  XIV. 
AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

PAGE 

Actions  of  the  Muscles  of  the  Eye — Paralysis  of  External  Rectus — 
Paralysis  of  the  Thii-d  Nerve — Paralysis  of  the  Internal,  Superior, 
and  Inferior  Recti,  and  of  the  Inferior  Oblique — Paralysis  of  Superior 
Oblique — Nystagmus — Strabismus — Convergent  Strabismus — Diver- 
gent Strabismus — Operations  for  Strabismus,  Von  Graefe's,  Critchett's, 
Liebreich's — Insufficiency  of  the  Internal  Recti  Muscles  . .  . .    548-604 

Chaptee  XV. 

DISEASES  OF  THE  LACHRYMAL  APPARATUS. 

Diseases  of  the  Lachi'ymal  Grland — Stniicidium  Lacrymarum — Inflammation 
of  the  Lachrymal  Sac — Blenon'hoea  of  the  Sac — Strictiire  of  the  Lachry- 
mal Passages — Fistula  of  the  Lachrymal  Sac     . .  . .  . .  . .    605-626 

Chapter  XVL 

DISEASES  OF  THE  ORBIT. 

Inflammation  of  the  Cellular  Tissue — Periostitis — Caries  and  Necrosis — 
Inflammation  of  the  Capsule  of  Tenon — Exophthalmic  Goitre — 
Tumovirs  of  the  Orbit — Vascular  Tumours  of  the  Orbit — Effusion  of 
Blood — Emphysema — Pressiire  upon  the  Orbit  from  Neighboui'ing 
Cavities — Wounds  and  Injuries  of  the  Orbit — Excision  of  the  Eyeball 
—The  AppUcation  of  Artificial  Eyes 627-667 

Chapter  XVII. 

DISEASES  OF  THE  EYELIDS. 

(Edema  and  Inflammation  of  the  Eyelids — Syphilitic  and  Exanthematous 
Afl'ections — Blepharitis  Marginalis — Ephidrosis  and  Chromhydrosis — 
Hordeolum — Tumours  of  the  Eyelids — Ptosis — Paralysis  of  the 
Orbicularis — Blepharospasm — Trichiasis  and  Distichiasis — Entropium 
— Ectropitmi— Injm-ies,  Woimds,  etc.,  of  the  Eyelids  . .  . .  . .    668-7X7 


A  TREATISE 


ON   THE 


DISEASES    OF    THE    EYE 


INTRODUCTION. . 

In  order  to  avoid  lannecessary  repetition  in  tlie  course  of  this  work, 
I  think  it  advisable  to  give  in  this  introduction  a  brief  description  of 
some  of  the  more  important  and  frequent  modes  of  examination  of  the 
eye,  as  well  as  of  certain  remedies  and  appliances  in  common  use  in 
ophthalmic  practice. 

Eversion  of  the  dipper  eyelid  has  frequently  to  be  practised  if  the 
presence  of  a  foreign  body  is  suspected  beneath  it,  or  if  certain 
remedies  are  to  be  applied  to  its  lining  membrane.  Various  contriv- 
ances have  been  suggested  for  facilitating  this  proceeding,  but  it  is 
best  done  in  the  following  manner : — The  patient  being  directed  to 
look  downwards,  the  surgeon  seizes  lightly  the  central  lashes  of  the 
upper  lid  between  the  forefinger  and  thumb  of  his  left  hand,  and 
draws  the  lid  downwards,  and  somewhat  away  fi'om  the  eyeball.  He 
next  places  the  tip  of  the  forefinger  of  his  right  hand  on  the  centre  of 
the  lid,  about  half  an  inch  from  its  free  margin,  With  a  quick  move- 
ment, the  edge  of  the  lid  is  to  be  then  turned  over  the  tip  of  the  fore- 
finger (which  should  be  simultaneously  somewhat  pressed  downwards). 
By  slightly  pressing  the  edge  of  the  everted  lid  backwards  against  the 
upper  edge  of  the  orbit,  the  whole  retro-tarsal  fold  will  spring  into 
view,  and  the  lid  become  fully  everted.  In  those  exceptional  cases  in 
which  the  patient  is  very  unmanageable,  and  forcibly  contracts  the 
orbicularis  muscle,  it  may  be  necessary  to  use  a  probe,  or  the  end  of  a 
quill  pen  or  pencil,  over  which  to  turn  the  lid,  instead  of  the  fore- 
finger. But  as  a  rule  it  is  more  convenient  to  employ  the  latter,  as  we 
may  not  always  have  a  probe  at  hand,  and  as  anything  in  the  shape  of 
an  instrument  frightens  some  patients,  whereas  we  may  often  succeed 
in  everting  the  lid  with  the  finger,  before  they  have  even  time  to  resist. 
The  surgeon  may  also  stand  behind  the  patient,  and  steady  the  head  of 
the  latter  against  his  breast,  and  evert  the  lid  from  behind. 

B 


INTRODUCTION. 


The  oblicpie  or  focal  illumination  is  in  constant  requisition  for  ascer- 
taining the  condition  of  the  structures  of  the  anterior  half  of  the  eye- 
ball. Bj  its  aid  we  are  enabled  to  examine  with  great  minuteness  the 
appearances  presented  by  the  cornea,  iris,  pupil,  lens,  and  even  the 
most  anterior  portion  of  the  vitreous  humour.  This  mode  of  examina- 
tion is  to  be  thus  conducted  : — A  lamp  being  placed  somewhat  in  front 
and  to  one  side  of  the  patient,  at  a  distance  of  from  2 — 2^  feet  [fig.  1], 
and  on  a  level  with  his  eye,  the  light  is  concentrated  upon  the  cornea 
or  the  crystalline  lens  by  a  strong    bi-convex  lens  of  2 — 2^  inches 

Fig.  1.  . 


focus.  The  observer's  eye  is  then  to  be  placed  on  one  side  of  the 
patient,  so  as  to  catch  the  rays  emanating  from  the  eye  of  the  latter. 
By  shifting  the  cone  of  light  fi-om  one  portion  of  the  cornea  or  lens  to 
another,  we  may  rapidly,  yet  thoroughly,  examine  their  whole  expanse 
and  detect  the  slightest  opacity.  In  order  to  gain  a  larger  image,  we 
may  employ  a  second  lens  as  a  magnifying  glass.  Opacities  of  the 
cornea  or  lens  will  appear  by  the  oblique  illumination  (reflected 
light)  of  a  hght  grey  or  whitish  colour,  whereas  with  the  ophthalmo- 
scope (transmitted  light)  they  will  appear  as  dark  spots  upon  a  bright 
red  background. 

The  method  of  examining  the  eye  with  the  ophthalmoscope  vidll  be 
found  described,  at  length,  in  the  section  upon  the  ophthalmoscope. 


The  mode  of  ascertaining  the  degree  of  intra-ocidar  tension  is  as 
follows  : — The  patient  being  directed  to  look  slightly  downwards,  and 
gently  to  close  the  eyelids,  the  surgeon  applies  both  his  forefingers  to 
the  upper  part  of  the  eyeball  behind  the  region  of  the  cornea.  The 
one  forefinger  is  then  pressed  slightly  against  the  eye  so  as  to  steady 
it,  whilst  the  other  presses  gently  against  the  eye,  and  estimates  the 
amount  of  tension,  ascertaining  whether  the  globe  can  be  readily  dimpled, 
or  whether  it  is  perhaps  of  a  stony  hardness,  yielding  not  in  the  slightest 
degree  even  to  the  firm  pressure  of  the  finger.  The  beginner  will  do 
well  to  make  himself  thoroughly  conversant  with  the  normal  degree  of 
tension,  by  the  examination  of  a  number  of  healthy  eyes,  and  then,  if 


INTRODUCTIOX.  3 

he  should  be  at  all  in  doubt  as  to  the  degree  of  tension  in  any  indi- 
vidual case,  he  should  test  the  tension  of  the  patient's  other  eye  (if 
healthy),  or  that  of  some  normal  eye,  so  as  to  be  able  to  draw  a  com- 
parison between  them.  If  there  is  much  cedema  of  the  lids,  or  con- 
junctival chemosis,  or  if  the  eyes  are  small  and  deeply  set,  it  may  be 
difficult  accurately  to  estimate  the  degree  of  tension. 

I  would  call  particular  attention  to  the  signs  which  Mr.  Bowman 
has  devised  for  the  designation  of  the  different  degrees  of  tension  of 
the  eyeball,  as  they  will  be  found  most  useful,  not  only  in  practice,  but . 
also  in  the  reporting  of  cases,  or  in  the  preservation  of  an  accurate 
record  of  the  state  of  tension. 

Mr.  Bowman  introduced  this  subject  to  the  attention  of  the  pro- 
fession in  1862,  in  liis  admirable  paper  "On  Glaucomatous  Affections, 
and  their  Treatment  by  Iridectomy,"  read  before  the  Annual  Meeting 
of  the  British  Medical  Association,*  in  which  he  says,  "I  have  long 
paid  special  attention  to  the  subject  of  tension  of  the  globe,  and  par- 
ticularly since  it  has  assumed  so  much  additional  importance  in  the 
last  few  years.  I  have  found  it  possible  and  practically  useful  to  dis- 
tinguish nine  degTees  of  tension ;  and,  for  convenience  and  accuracy 
in  note-taking,  have  designated  them  by  special  signs.  The  degrees 
may  be  thus  exhibited  :t 

"  T  represents  tension  ('  t '  being  commonly  used  for  'tangent,'  the 
capital  T  is  to  be  preferred).  Tn,  tension  normal.  The  interrogative,  ?, 
marks  a  doubt,  which  in  such  matters  we  must  often  be  content  with. 
The  numerals  following  the  letter  T,  on  the  same  line,  indicate  the 
degree  of  increased  tension;  or  if  the  T  be  preceded  by  — ,  oi  diminished 
tension,  as  farther  explained  below.     Thus  : 

"  T  3.  Third  degree,  or  extreme  tension.  The  fingers  cannot  dim- 
ple the  eye  by  firm  pressure. 

"  T  2.  Second  degree,  or  considerable  tension.  The  finger  can 
slightly  impress  the  coats. 

"  T  1.  First  degree,  slight  hut  i^ositive  increase  of  tension. 

"TIP.  Doubtful  if  tension  is  increased. 

"  Tn.  Tension  normal. 

"  — T  1  ?.  Doubtful  if  tension  be  less  than  natural. 

"  —  T  1.  First  degree  of  reduced  tension.  Slight  but  positive 
reduction  of  tension. 

"  —  T  2  1  Successive  degrees  of  reduced  tension,   short   of  such 

"  —  T  3  /  considerable  softness  of  the  eye  as  allows  the  finger  to 
sink  in  the  coats.     It  is  less  easy  to  define  these  by  words. 

*  "  British  Medical  Journal,"  Oct.  11th,  1862,  p.  378. 

t  "  Since  this  paper  -was  read  I  have  simplified  the  signs,  with  the  concui-rence 
of  my  friend.  Professor  Bonders,  in  order  to  adapt  them  for  general  use.  The  sim- 
plified form  has  been  substituted  abore." 

B    2 


4  INTRODUCTION. 

"  In  common  practice,  some  of  these  may  be  regarded  as  refine- 
ments ;  but  in  accurate  note-taking,  where  the  nature  and  course  of 
various  diseases  of  the  globe  are  under  investigation,  I  have  found 
them  highly  ser-\dceable,  and  they  have  as  much  precision  as  perhaps 
is  attainable  or  desirable. 

"  It  is  also  to  be  borne  in  mind  that  the  normal  tension  has  a 
certain  range  or  variety  in  persons  of  different  age,  build,  or  tempera- 
ment ;  and  according  to  varying  temporary  states  of  system  as 
regards  emptiness  or  repletion.  Experience  will  make  every  one 
aware  of  these  varieties,  which  do  not  encroach  on  the  above  abnor- 
mal grades  of  tension.  Medical  men  may  understand  how  important 
is  this  matter  of  the  degree  of  tension,  by  considering  how  priceless 
would  be  the  power  of  accurately  estimating  it  hy  the  toucli,  in  the  case 
of  various  head  affections.'''' 

For  the  examination  of  the  acuteness  of  vision  various  test-types 
are  used,  more  especially  those  of  Jaeger  and  Snellen.  The  former 
do  not,  however,  afford  a  perfect  clue  to  the  acuteness  of  vision,  for  a 
person  may  be  able  to  read  No.  1  of  Jaeger  with  facility  and  yet  not 
enjoy  a  normal  acuteness  of  sight.  Snellen  has,  however,  devised  a 
set  of  test-types  which  fulfil  this  desideratum.  The  lettere  are  square 
and  their  size  increases  at  a  definite  ratio,  so  that  each  number  is  seen 
at  an  angle  of  five  minutes.  Thus,  No.  1  is  seen  by  a  normal  eye  up 
to  a  distance  of  one  foot,  at  an  angle  of  five  minutes,  No.  2  up  to  two 
feet,  and  so  on.  Tliese  numbers  cannot,  as  a  rule  be  seen  distinctly 
beyond  these  distances.* 

Now,  if  the  eye  is  suffering  from  any  diminution  of  acuteness  of 
vision,  it  wiU  require  to  see  the  letters  under  a  larger  angle  than  that 
of  five  minutes,  in  order  to  gain  larger  retinal  images.  No.  1  cannot 
be  read  at  a  distance  of  one  foot,  but  only,  perhaps,  No.  4  or  5.  We 
may  easily  calculate  the  degree  of  the  acuteness  of  vision  thus  : 

"  The  utmost  distance  at  which  the  types  are  recognised  (d) 
divided  by  the  distance  at  which  they  appear  at  an  angle  of  five 
minutes   (D),  gives  the  formula   for   the  acuteness  of  vision    (Y)  : 

-  =  ^- 

*  AtProfessorLongmore'ssuggesfcion,  Dr.  Snellen  1ms  given  in  his  second  edition 
of  the  test-types  some  tables  containing  a  series  of  figures  and  single  numbers,  for  the 
examination  of  such  recruits  for  the  British  army  as  are  unable  to  read.  For  fur- 
ther information  as  to  the  examination  of  the  sight  of  recruits,  I  must  refer  the 
reader  to  Professor  Longmore's  cxcellcut  "  Ophthalmic  Manual,"  which  I  would 
also  recommend  to  the  especial  notice  of  the  surgeons  of  the  Militia  and  Volunteer 
Corps.  These  test-types  may  bo  obtained  at  Messi's.  Williams  aud  Norgate's,  Hcu- 
rietta-street,  Covent  Garden. 


INTRODUCTION.  5 

"  If  d  and  D  be  found  equal,  and  No.  20  be  thus  visible  at  a  distance 

20 
of  twenty  feet,  then  V  =   -    =  1 ;  in   other  words,  there  is  normal 

acuteness  of  vision.  If,  on  the  contraiy,  d  be  less  than  D,  and  if  No.  20 
is  only  visible  within  ten  feet.  No.  10  only  within  two  feet,  No.  6  only 
within  one  foot,  these  three  cases  are  thus  respectively  expressed  : 

20       2'  10       5'  6 

d  may  sometimes  be  greater  than  D,  and  No.  20  be  visible  at  a  greater 
distance  than  twenty  feet.  In  this  case  vision  is  more  acute  than  the 
normal  average." 

It  must,  however,  be  confessed  that  some  patients  (more  especially 
amongst  the  lower  classes)  often  experience  a  difficulty  in  fluently 
reading  type  composed  of  these  square  letters.  They  have  always 
been  accustomed  to  ordinary  type,  the  letters  of  which  are  of  unequal 
thickness,  and  differ  both  in  dimension  and  definition.  I,  therefore, 
generally  employ  Jaeger's  test-types  for  ascertaining  the  fluency  with 
which  small  print  can  be  read,  and  those  of  Snellen,  for  testing  with 
accuracy  the  acuteness  of  vision. 

Besides  examining  the  acuteness  of  vision,  it  is  often  of  much 
importance  to  ascertain  with  accuracy  and  care  the  condition  of  the 
field  of  vision,  which  may  be  readily  done  in  the  following  manner  : — 
The  patient,  being  placed  straight  before  us,  at  a  distance  of  from 
fifteen  to  eighteen  inches,  is  directed  to  look  with  the  eye  under 
examination  (closing  the  other  with  his  hand)  into  one  of  our  eyes, 
his  right  eye  being  fixed  upon  our  left,  and  vice  versa.  In  this  way 
any  movement  of  the  eye  may  be  at  once  detected  and  checked. 
Whilst  he  still  keeps  his  eye  steadily  fixed  upon  ours,  we  next  move 
one  of  our  hands  in  different  directions  throughout  the  whole  extent 
of  the  field  of  vision  (upwards,  downwards,  and  laterally),  and  ascer- 
tain how  far  from  the  optic  axis  it  is  still  visible  ;  we  then  approach 
the  hand  nearer  to  the  optic  axis,  and  examine  up  to  how  far  from  it  he 
is  able  to  count  fingers  in  different  directions.  The  number  of  the 
extended  fingers  is  to  be  constantly  changed,  and  the  examination  to 
be  repeated  several  times,  so  that  we  may  ascertain  whether  the 
patient  can  count  them  with  certainty,  or  whether  he  hesitates  in  his 
answers,  or  only  g-uesses  at  their  number.  We  may  thus  readily  dis- 
cover whether  the  field  of  vision  is  of  normal  extent,  or  whether  it  is 
defective  or  altogether  wanting  in  certain  directions. 

We  may  term  that  part  of  the  field  in  which  the  patient  can  still 
distinguish  an  object  (a  hand,  a  piece  of  chalk,  &c.)  the  quantitative 
field  of  vision,  in  contradistinction  to  that  smaller  portion  in  which 


6  INTRODUCTION. 

he  is  able  to  count  fingers,  and  wliicli  may  be   designated  the  qualita- 
tive field. 

The  following  method  of  examining  the  field  is  still  more  accurate, 
and  I  should  advise  its  adoption  in  all  cases  where  it  is  of  importance 
to  have  an  exact  map  of   the  extent  of  the  field,  as  in   glaucoma, 
detachment  of  the  retina,   &c.,   so  that  a  record  may  be  kept  of  the 
condition  of  the  field  during  the  progress  of  the  disease,  or  that  we 
may  be  able  to  compare  its  extent  before  and  after  an  operation.     The 
patient  being  placed  before  a  large  black  board,  at  a  distance  of  from 
twelve  to  16  inches,  is  directed  to  close  one  eye  and  to  keep  the  other 
steadily  fixed  upon  a  chalk  dot,  marked  in  the  centre  of  the  board  and 
on  a  level  with  his  eye.     A  piece  of  chalk,  fixed  in  a  dark  handle,  is 
then  gradually  advanced  from  the  periphery  of  the  board  towards  the 
centre,  and  the  spot  where  the  chalk  first  becomes  visible  is   then 
marked  upon  the  board.     This  proceeding  is  to  be  repeated  throughout 
the  whole  extent  of  the  field  ;  the  difierent  points  at  which  the  object 
first  becomes  visible  are  then  to  be  united  by  a  line,  which  indicates 
the   outline  of   the   quantitative  field  of  vision.     The  extent   of  the 
qualitative  visual  field  is  next  to  be  examined,  and  it  is  to  be  ascer- 
tained how  far  from  the   central  spot  the  patient  can  count  fingers  in 
difierent  directions.     The  points  thus  found  are  also  to  be  marked  on 
the  board,  and  the  marks  afterwards  united  with  each  other  by  a  line, 
which  should  be  of  a  difierent  colour  or  character  to  that  indicating 
the  extent  of  the  quantitative  field,  so  that  the  two  may  not  be  con- 
founded.    It  need  hardly  be  mentioned   that  care  is  to  be  taken  that 
during  the  examination  the  patient's  eye  remains  steadily  fixed  upon 
the  central  spot,  that  the  other  eye  is  kept  closed,  and  that  his  dis- 
tance from  the  board  is  not  altered.     The  extent  of  the   field  inwards 
will,  naturally,  vary  according  to  the  prominence  of  the  patient's  nose. 
It  is  still  more  convenient  to  map  out  the  field  upon  a  large  piece 
of  blue  paper  placed  against  the  board,  as  this  saves  us  the  trouble  of 
copying  the  map  from  the  latter.     Such  maps  are  to  be  kept  for  future 
reference,  or  for  comparison  with  others  that  may  be  taken  of  the  same 
case  at  a  later  period.     If  this,  however,  cannot  be  done,  we  may  keep 
a  record  of  the  shape  of  the  field,  and  of  the  distance  to  which  the 
patient  can  see  in  difierent  segments  of  it,  by  the  following  simple 
expedient  which  I  have  for  some  time  adopted. 

The  board  is  to  be  divided  into  four  equal  parts  by  a  vertical  and 
horizontal  line  (of  about  4  feet  in  length),  cutting  each  other  at  the 
central  cross ;  each  quadrant  is  then  again  to  be  divided  into  two 
equal  parts  by  another  line,  so  that  the  whole  is  divided  into  eight 
equal  segments,  as  in  the  accompanying  figure  (fig.  2)  which  repre- 
sents the  division  of  the  field  for  the  left  eye.  For  the  right  eye 
the  position  of  the  letters  must  be  reversed,  thus  ^^,  i  (upwards  and 


INTRODUCTION.  7 

inwards),  would  be  u  o  (upwards  and  outwards),  and  so  with  all  the 
others. 

The  meaning  of  the  letters  is  as  follows  : — 

V  M — Vertical  Meridian,  dividing  the  field  into  two  lateral  halves 
(inner  and  outer). 

H  Mr — Horizontal  Meridian,  dividing  the  field  into  an  upper  and  a 
lower  half. 

The  upper  half  of  the  field  is  subdivided  into  four  segments : — 

u  0  upper  and  outer  segment. 
0  u  outer    ,,     upper        ,, 
u  i  upper    ,,     inner        ,, 
i   u  inner    ,,     upper       ,, 

The  lower  half  is  also  subdivided  into  four  segments  : — 

0  Z  outer  and  lower  segment. 

1  0  lower  „  outer  ,, 
i  I  inner  ,,  lower  ,, 
I    i  lower    ,,     inner         ,, 


Fig.  2. 
Left  Eye. 


VM 


^ 

U  0 

U  I 

y 

ou 

\ 

XM 

ol 

lo 

li 

il 

8  INTRODUCTION. 

The  metliod  of  examining  the  patient's  field  of  vision  is  to  be  the 
same  as  that  above  described,  when  a  plain  board  was  nsed.  The 
object  of  the  divisions  is  only  to  furnish  a  kind  of  fi^amework  for  the 
m.ap  of  the  field,  which  enables  ns  to  sketch  it  with  more  ease  and 
rapidity.  The  boundary  of  the  quantitative  and  qualitative  fields  is  to 
be  marked  both  upon  and  between  each  of  the  divisional  lines,  and 
the  distance  of  each  of  these  marks  from  the  centre  of  the  board  is 
then  to  be  measured,  and  its  extent,  in  inches,  is  to  be  placed  against 
each  mark.  A  small  fac-simile  of  the  field  of  vision  thus  mapped  out, 
may  then  be  drawn  in  the  note-book,  the  field  being  here  also  divided 
into  eight  segments,  the  boundaries  and  measurements  of  the  map 
being  likewise  copied ;  so  that  we  may  preserve,  in  a  small  and  con- 
venient form,  an  accurate  record  of  the  shape  and  extent  of  the  visual 
field. 

But  the  sight  of  the  patient  may  be  so  much  impaired  that  he  can 
no  longer  count  fingers,  even  in  the  optic  axis,  being  only  able  to  dis- 
tinguish between  light  and  dark,  as  in  cases  of  mature  cataract, 
severe  cases  of  glaucoma,  etc.,  and  yet  it  may  be  of  great  importance  to 
know  whether  or  not  the  field  of  vision  is  of  normal  extent.  This  may 
be  readily  ascertained  in  the  following  manner : — The  patient  is  directed 
to  look  with  the  one  eye  (the  other  being  closed)  in  the  direction  of  his 
uplifted  hand  (held  on  a  level  with  his  eye,  and  at  a  distance  of  from 
12  to  18  inches).  A  lighted  candle  is  then  held  in  different  portions  of 
the  visual  field,  and  the  furthest  point  at  which  it  is  still  visible  in 
various  directions  is  noted,  the  candle  being  alternately  shaded  and 
uncovered  by  our  hand,  so  as  to  test  the  readiness  and  accuracy  of  the 
patient's  answers.  Care  should  also  be  taken  to  shade  the  candle  when 
it  is  removed  to  another  portion  of  the  field.  The  light  may  also  be 
thrown  upon  various  portions  of  the  eyeball  by  the  mirror  of  the 
ophthalmoscope,  and  the  patient  questioned  as  to  the  direction  from 
which  the  light  appears  to  come. 

Mr.  Pridgin  Teale  has  devised  a  modification  of  the  above  method, 
by  subdividing  the  board  (already  divided  by  vertical,  horizontal,  and 
diagonal  lines)  by  a  series  of  concentric  circles.  There  is,  moreover, 
a  travelling  white  disc  of  card  board,  which  can  be  moved  from  the 
outer  edge  of  the  board  to  the  centre  along  the  diagonal  and  other  lines, 
thus  forming  a  very  convenient  and  easily  recognisable  object.  There 
is  also  a  rest  to  steady  the  patient's  head,  and  maintain  it  at  a  certain 
distance.  He  marks  the  existence  of  good  vision  by  a  +  sign,  imper- 
fect vision  by  — ,  and  absence  of  vision  by  0.  Blank  diagrams  are 
prepared,  which  are  a  copy  of  the  markings  on  the  board,  on  a  scale 
of  ^  of  an  inch  to  1  inch  of  the  board. 

Wecker  employs  the  following  mode  of  taking  the  field.  He  uses  a 
large  black  board,  towards  the  centre  of  which  can  be  moved  in  a 


INTRODUCTION. 


radiating  direction  a  number  of  small  white  ivory  balls,  thus  marking 
the  extent  of  the  field ;  as  soon  as  the  ball  reaches  the  limit  of  the 
field,  it  is  turned  round,  and  presents  its  black  posterior  surface  to  the 
patient.  On  the  back  portion  of  the  board,  the  shape  and  extent  of 
the  field  can  be  read  ofi"  from  the  position  of  the  white  balls,  which  give 
its  exact  delineation. 

Double  images  {diplopia). — An  object  only  appears  single  when  both 
optic  axes  are  fixed  upon  it ;  any  pathological  deviation  of  either  optic 
axis  must  necessarily  cause  diplopia,  as  the  rays  from  the  object  do  not 
then  fall  upon  identical  portions  of  the  retina.  The  slightest  degree 
of  diplopia  is  that  in  which  the  double  images  are  not  distinctly 
defined,  but  seem  to  lie  slightly  over  each  other,  so  that  the  object 
appears  to  have  a  halo  round  it. 

We  meet  with  two  kinds  of  double  images. 

1.  Homonymous  (or  direct)  diplopia,  in  which  the  image  to  the 
right  of  the  patient  belongs  to  his  right  eye,  the  left  image  to  the 
left  eye. 

2.  Crossed  double  images,  in  which  case  the  iruage  to  the  right  of 
the  patient  belongs  to  his  left  eye,  that  on  his  left  to  his  right  eye. 

Homonymous  diplopia  is  always  produced  (except  in  incongruence 
of  the  retinje)  in  convergent  squint,  for  if  the  eye  deviates  inwards 
from  the  object,  the  rays  coming  from  the  latter  will  fall  upon  the  inner 
portion  of  the  retina,  and  the  image  will  (in  accordance  with  the  laws 
of  projection)  be  projected  outwards,  as  in  fig.  3. 

Let   I.   be   the  rig'ht  eye,  „. 

whose  optic  axis  is  fixed  upon 
the  object  (b).  II.  The  left 
eye,  whose  optic  axis  (c  d) 
deviates  inwards  from  the 
object ;  the  rays  from  b  there- 
fore fall  upon  e,  a  portion  of 
the  retina  internal  to  the  yel- 
low spot  (d),  and  the  image  is 
consequently  projected  out- 
wards to  f ;  b  and  f  are,  there- 
fore, homonymous  double 
images,  the  image  b,  which  is 
to  the  right  of  the  patient, 
belonging  to  his  right  eye,  the 
image  f  to  his  left  eye. 

Crossed  double  images  arise  in  divergent  squint,  for  as  the  one 
eye  deviates  outwards  from  the  object,  the  rays  from  the  latter  fall 
upon  a  portion  of  the  retina  external  to  the  macula  lutea,  the  image 
is  projected  inwards,  and  crosses  that  of  the  other  eye,  as  in  fig.  4. 


II. 


I. 


10 


INTRODUCTION. 


II. 


I. 


I.  Tlie  riglit  eye,  wliose  optic  axis  is  fixed  upon  the  object  (b). 
TI.  The  left  eye,  whose  optic  axis   (c  d)    deviates  outwards  from  the 

object ;  the  rays  from  the 
latter  therefore  fall  upon  e, 
a  portion  of  the  retina  exter- 
nal to  the  macula  lutea  (d), 
and  the  image  is  projected  to 
f,  crossing  the  image  b ;  the 
image  f,  which  would  lie  on 
the  patient's  right  hand, 
would,  therefore,  belong  to 
his  left  eye,  the  image  b, 
which  would  lie  on  his  left 
side,  to  the  right  eye. 

If  one  eye  squints  up- 
wards, the  rays  will  fall  upon 
the  upper  portion  of  the 
retina,  and  the  image  be  pro- 
jected beneath  that  of  the 
healthy  eye.  The  reverse  will  be  the  case  if  the  eye  squints  down- 
wards, for  then  the  rays  will  fall  upon  the  lower  portion  of  the  retina, 
and  the  image  will  be  projected  above  that  of  the  healthy  eye. 

We  should  never  forget  to  ascertain  whether  the  diplopia  be 
monocular  or  binocular ;  in  the  latter  case,  it  will  of  course  disappear 
upon  the  closu.re  of  either  eye.* 

Let  us  now  glance  at  the  action  of  prisms.  When  a  ray  of  light 
falls  upon  a  prism,  it  is  refracted  towards  its  base.  If,  for  instance, 
whilst  we  look  at  an  object  (e.  g.,  a  lighted  candle)  at  8  feet  distance 
with  both  eyes,  a  prism,  with  its  base  towards  the  nose,  is  placed  before 
the  right  eye,  the  rays  from  the  candle  will  be  deflected  towards  the  base 
of  the  prism,  and  fall  upon  a  portion  of  the  retina  internal  to  the 
yellow  spot,  and  be  consequently  projected  outwards,  giving  rise  to 
homonymous  diplopia.  As  we  are,  however,  very  susceptible  of  double 
images,  the  eye  will  endeavour  to  unite  them  by  an  outward  move- 
ment (its  external  rectus  becoming  contracted),  which  will  again  bring 
the  rays  upon  the  yellow  spot,  but  at  the  same  time  of  course  cause  a 
divergent  squint.     Fig.  5  will  explain  this.     Let  a  b  bo  the  optic  axis 


*  In  examining  the  double  images  of  a  patient,  it  is  eonvenient  to  place  a  slip  of 
red  glass  before  the  sound  eye,  for  vre  thus  enable  him  readily  to  distinguish  the 
two  images  by  their  colour,  and  we  also  weaken  the  intensity  of  the  image  of  the 
sound  eye,  and  approximate  it  more  to  that  of  the  affected  one,  whose  image,  owing 
to  the  rays  from  the  object  falling  upon  an  eccentric  portion  of  the  retina,  will  be 
less  intense  in  proportion  to  the  distance  of  the  spot,  upon  which  the  rays  fall,  from 
tlie  macula  lutea. 


INTRODUCTION.  11 

of  the  left  eye  fixed  (with  the  other)  iipon  a  candle  8  feet  off.     Now,  if 

a  prism  (with  its  base  towards  the  nose)  be  placed  before  the  right  eye, 

the    rays    are    refracted    towards    tlie 

base  of  the  prism   and  do  not,   as  in  'S'     " 

the    other   eye,   fall  iipon    the    yellow 

spot,  but  on  a  portion  of  the   retina 

(d)   internal    to    the    latter,    and    the 

image   is  projected    outwards     to    e ; 

homonymous  diplopia  therefore  arises, 

and  to  avoid  this  the  external  rectus 

m.uscle  contracts    and  moves  the  eye 

outwards,  so  as  to  bring  the  macula 

lutea    (c)  to    that  spot  (d)  to  which 

the  rays  are  deflected  by  the  prism. 

As   the  rays  from  the  object  will  now 

fall    in    both    eyes   upon   the    macula 

lutea,  single  vision  will  result,  accompanied,  of  course,  by  a  diver- 
gent squint  of  the  right  eye. 

The  reverse  will  occur  if  we  turn  the  prism  w^ith  its  base  to  the 

temple,  for  then  the  rays  will  be  deflected  to  a  portion  of  the  retina  to 
the  outer  side  of  the  macula  lutea,  and  the  image  will  be  projected 
inwards  across  that  of  the  left  eye,  and  crossed  diplopia  will  be  the 
result.  In  order  to  remedy  this,  the  internal  rectus  will  contract  and 
move  the  eye  inwards,  so  as  to  bring  the  macula  lutea  to  that  spot  to 
which  the  rays  are  deflected. 

The  Compress  Bandage. — The  form  of  bandage  to  be  employed,  as 
well  as  its  mode  of  application  to  the  eye,  is  of  much  practical  import- 
ance, and  it  should  vary  according  to  the  effect  which  we  desire  to 
produce.  If  the  bandage  is  applied  only  for  the  purpose  of  keeping 
the  dressing  upon  the  eye,  of  preventing  the  movement  of  the  latter 
and  of  the  eyelids,  or  of  guarding  the  eye  against  the  effect  of  light  or 
cold,  it  need  be  but  of  a  very  simple  kind,  and  I  think  Liebreich's 
bandage  answers  these  purposes  best.  But  Von  Graefe  has  shown  that 
the  compress  and  bandage  may  often  be  made  of  great  therapeutical 
value,  especially  in  an^esting  and  limiting  suppui'ative  inflammation  of 
the  cornea,  such  as  is  apt  to  occur  in  old  and  decrepid  persons  after 
injuries  to  the  cornea,  or  an  operation  {e.g.,  extraction  of  cataract). 
In  such  cases  Liebreich's  bandage  does  not  suffice,  and  we  must 
employ  the  pressure-bandage  of  Von  Graefe, 

Liebreich's  bandage  consists  of  a  knitted  cotton  band  about  12 
inches  long  and  2^  inches  wide.  At  the  one  end  are  two  tapes,  the  one 
going  round  the  back  of  the  head,  the  other  forming  a  cross-bar  with 
the  first,  and  passing  over  the  top  of  the  head.  The  other  end  of  the 
bandage  also  carries  a  tape  which  is  to  be  tied  at  the  side  of  the  head, 


12  INTRODUCTION. 

opposite  the  affected  eye,  to  the  one  coming  round  from  the  back.  The 
principal  advantages  offered  by  this  bandage  are — that  it  perfectly 
retains  its  position  without  slipping,  and  that  it  can  be  undone  and  the 
dressings  changed  without  the  patient's  head  having  to  be  raised  from 
the  pillow.  If  the  thick  knitted  band  proves  heavy  and  hot,  I  substi- 
tute for  it  a  band  of  fine  muslin  or  of  elastic  web.  The  bandage  is  to 
be  applied  over  the  following  dressing : — The  patient  being  dir*ected 
gently  to  close  his  eyes,  a  piece  of  soft  linen  is  laid  over  the  lids  so  as 
to  soak  up  any  discharge,  small  oval  pledgets  of  charpie*  or  carded 
cotton- wool  are  then  placed  over  this,  more  especially  in  the  hollow  at 
the  inside  of  the  eyeball  and  beneath  the  upper  edge  of  the  orbit,  so  as 
to  fill  these  out,  and  bring  the  padding  nearly  to  the  same  level  as  in 
the  centre.  The  pressure  of  this  cushion  should  be  quite  uniform,  and 
not  greater  upon  one  portion  of  the  eye  than  another,  more  especially 
upon  the  centre  of  the  eyeball,  otherwise  it  will  produce  pain  and  dis- 
comfort. The  succession  of  the  pledgets  of  charpie  should  be  applied  in 
such  a  manner  that  the  upper  lid  is  gently  stretched  across  the  eyeball 
in  a  lateral  direction,  and  the  lids  thus  kept  immoveable.  The  two 
principal  points  of  pressui'e  should  be  at  the  inner  and  outer  canthus, 
so  that  the  eyeball  is  only  pressed  by  the  upper  lid  being  stretched 
gently  across  it. 

Von  Graefef  makes  use  of  three  different  forms  of  compressive 
bandages — 1,  the  temporary ;  2,  the  regular  compress ;  3,  the  pressure 
compress. 

1.  Tlie  temporarij  bandage  simply  consists  of  a  knitted  cotton 
band  about  15  inches  in  length  and  1|-  inch  in  width,  which  is  to  be 
placed  over  the  eye  and  fastened  by  a  couple  of  tapes.  For  this  pur- 
pose I  think  Liebreich's  bandage  is  to  be  greatly  preferred,  but  with 
the  next  two  forms  of  bandage  it  is  different,  for  here  we  can  regulate 
the  degree  and  mode  of  pressure  desired  with  a,  nicety  and  accuracy 
not  to  be  obtained  with  Liebreich's. 

'  2,  The  Megular  •  Compress. — This  bandage  is  about  If  yard  long 
and  1^  inch  wide.  Its  outer  two-thirds  consist  of  fine  and  very 
elastic  flannel,  its  central  third  of  knitted  cotton.  The  eye  having 
been  padded  with  charpie  or  cotton  wool,  as  above  directed,  the  band- 
age is  to  be  thus  adjusted; — One  end  is  to  be  applied  to  the  forehead 
just  above  the  affected  eye,  and  is  then  to  be  passed  to  the  opposite 
side  of  the  forehead  and  above  the  ear  to  the  back  of  the  head;  the 

*  Charpie  consists  of  tlireads  of  very  fine  linen ;  the  linen  should  be  cut  into 
small  sqtiares  of  about  3  or  4  inches  in  diameter,  and  the  individual  threads  are 
then  to  be  pulled  out,  thus  forming  the  charpie,  wliich  should  then  be  folded  into 
small  pledgets.     This  is  much  cooler  and  more  comfortable  than  cotton  wool. 

t  A.  f.  O.  ix,  2 ;  vide  also  an  abridgement  of  this  paper,  by  the  author,  in  E.  L. 
O.  H.  Rep.  iv,  2. 


INTRODUCTION.  13 

knitted  portion  is  then  carried  on  below  the  ear  and  brought  upwards 
over  the  compress,  the  bandage  being  then  again  passed  across  the 
forehead  and  its  end  firmly  pinned.  The  opposite  eye  may  be  closed 
with  a  strip  of  plaster,  or,  should  it  also  require  a  compress,  a  separate 
bandage  is  to  be  applied. 

3.  The  pressure  bandage  is  made  of  fine  and  very  elastic  flannel,  and 
should  be  about  3|-  yards  long  and  1^  inch  wide.  It  is  intended  to 
produce  complete  immobility  of  the  eye,  and  to  exert  a  considerable 
degree  of  graduated  pressure.  The  one  end  of  the  bandage  is  to  be 
placed  upon  the  cheek,  at  a  point  about  midway  between  the  angle  of 
the  jaw  and  the  ear  of  the  affected  side,  and  the  bandage  brought  up 
over  the  compress  (but  not  applied  too  tightly)  and  carried  across  the 
forehead  to  the  back  of  the  head ;  and  then,  passing  beneath  the  ear, 
a  second  turn  is  to  ascend  (somewhat  more  vertically)  over  the  com- 
press, pressing  firmly  upon  the  latter.  The  bandage  is  then  again 
carried  across  the  forehead  to  the  back  of  the  head,  and  finally  brought 
once  more  over  the  compress,  but  this  time  it  is  not  to  be  pulled 
tight. 

Baron  Heiirtelo^ip^s  Artificial  Leech. — This  instrument  is  of  the 
greatest  service  in  the  abstraction  of  blood  in  deep-seated  intra- 
ocular diseases,  as,  for  instance,  in  inflammations  of  the  choroid, 
retina,  and  optic  nerve.  For  in  order  to  relieve  the  intra-ocular 
circulation,  it  is  necessary  that  the  depletion  should  be  rapid,  and  we 
find  that  in  the  inflammations  of  the  deeper  tunics  of  the  eye,  depletion 
by  leeches  is  almost  useless,  whereas  the  effect  of  the  artificial  leech 
is  very  considerable.  The  instrument  consists  of  a  small  sharp 
cylindrical  drill,  and  of  a  glass  exhausting  tube,  with  an  air-tight 
piston.  The  drill  can  be  set  so  as  to  make  the  incision  of  the  desired 
depth,  and  is  worked  by  a  string,  on  pulling  which  a  rapid  revolution 
of  the  drill  is  caused,  and  the  skin  consequently  deeply  incised.  The 
instrument  is  to  be  applied  to  the  temple,  and  the  hair  should  be 
previously  shaved  off  at  this  spot,  otherwise  it  will  get  between  the 
skin  and  the  edge  of  the  exhausting  tube,  and  thus  cause  the  admission 
of  air.  The  incision  should  be  made  tolerably  deep  (the  depth  varying 
of  course  with  the  thickness  of  the  skin),  in  order  that  the  blood  may 
flow  freely  and  rapidly.  The  air-tight  piston  is  then  to  be  applied  over 
the  incision,  and  a  few  rapid  turns  given,  so  that  the  skin  may  be  some- 
what sucked  up  into  the  tube.  The  blood  will  now  flow  very  rapidly, 
and  the  screw  in  the  piston  must  be  moved  in  accordance  with  the 
flow  of  blood,  so  that  no  vacuum  exists  between  the  plug  and  the 
column  of  blood,  nor  should  the  screw  be  moved  roughly  and  too 
quickly,  otherwise  it  may  produce  great  pain.  The  glass  cylinder 
(which  holds  about  1  oz.  of  blood)  should  be  filled  in  from  three  to 


14  INTRODUCTION. 

four  minutes.  The  plug  of  the  cyHnder  should  be  soaked  in  hot  water 
previous  to  the  operation,  so  that  it  may  swell  up  and  fit  very  tightly 
into  the  tube,  and  the  edge  of  the  latter,  which  is  applied  to  the  skin, 
should  be  greased  or  soaped,  in  order  that  it  may  fit  closely  to  the 
skin,  and  prevent  the  entrance  of  air.  With  a  little  practice  the 
operation  may  be  gently,  yet  efiectually  performed  without  giving 
much  pain  to  the  patient.  Hot  fomentations  should  be  applied  after- 
wards, so  that  there  may  be  free  after  bleeding.  As  the  abstraction  of 
blood  near  the  eye  always  causes  considerable  increase  in  the  flow  of 
blood  to  the  part  and  its  vicinity,  the  patient  should  be  kept  in  a 
darkened  room  for  the  first  twenty- four  hours,  until  the  period  of  reac- 
tion is  passed.  At  first  the  sight  will  be  a  little  dim  and  indistinct, 
but  after  thirty  to  thirty-six  hours  have  elapsed,  the  beneficial  effects  of 
the  depletion  will  generally  be  marked. 

The  Bye-douche. — The  best  and  cheapest  form  of  this  instrument 
consists  of  a  piece  of  india-rubber  tubing  about  4^  feet  in  length, 
carrying  a  rose  at  one  end,  and  at  the  other  a  curved  piece  of  metallic 
pipe,  which  is  to  be  suspended  in  a  jug  of  water  placed  on  a  high 
shelf.  The  fine  jet  of  water  thrown  up  through  the  rose  will  be  about 
12  to  15  inches  in  height,  and  the  force  with  which  it  plays  upon  the 
eye  may  be  regulated  by  approximating  or  removing  the  latter  from  the 
rose.  This  form  of  eye-douche  is  to  be  preferred  to  that  which  is 
applied  by  means  of  a  cup  to  the  eye  itself,  as  the  jet  is  in  this  case  far 
too  strong,  and  often  increases  instead  of  alleviating  the  irritation.  It 
is  to  be  employed  night  and  morning,  or  oftener  if  the  eyes  feel  hot 
and  tired,  for  two  or  three  minutes  at  a  time.  The  eyelids  are  to  be 
closed,  and  the  stream  of  water  is  to  play  gently  upon  them. 

Mathieu's  (Paris)  water  pulverizer,  or  the  instrument  used  for 
Dr.  Richardson's  ether  spray,  will  also  be  found  very  useful  and 
agreeable. 


Chapter  I. 
DISEASES    OF     THE    CONJUNCTIVA. 


1.— HYPEREMIA  OF  THE  CONJUNCTIVA. 

We  not  unfrequently  meet  with  a  liyper^mic  condition  of  the  con- 
junctiva, and  it  is  of  practical  importance  to  distinguish  this  from  a 
mild  form  of  conjunctivitis.  In  the  former  condition  we  find,  on  evert- 
ing the  eyelids,  that  their  lining  membrane  is  abnormally  red,  and 
perhaps  a  little  swollen,  and  traversed  by  well-marked  meshes  of  blood- 
vessels, which  render  the  Meibomian  glands  somewhat  indistinct. 
This  increased  redness  may  extend  to  the  retro-tarsal  fold,  caruncle, 
semilunar  fold,  and  even  to  the  ocular  conjunctiva,  so  that  the  white  of 
the  eye  appears  flushed  and  injected.  The  papillas  of  the  conjunctiva 
may  also  be  slightly  swollen  and  turgid,  which  gives  a  somewhat  rough 
and  velvety  appearance  to  the  inside  of  the  lids.  The  patient  is  generally 
troubled  by  a  feeling  of  smarting  and  itching  in  the  eye,  and  a  heaviness 
and  weight  in  the  eyelids,  so  that  he  experiences  some  difficulty  in 
keeping  them  open.  These  sensations  become  worse  in  the  evening, 
more  especially  in  bright  artificial  light.  Sometimes  there  is  a  slight 
tendency  to  lachrymation  when  the  eyes  are  exposed  to  wind  or  a  smoky 
atmosphere,  but  there  is  no  trace  of  any  mucous  discharge. 

This  hypergemic  condition  may  be  produced  by  long- continued  work 
at  small  objects,  such  as  reading,  engraving,  microscopizing,  more  espe- 
cially by  strong  artificial  light.  It  is  also  not  unfrequently  a  reflex 
symptom  of  hypersemia  of  the  choroid  and  retina.  Thus  in  very  short- 
sighted persons  affected  with  sclerotico- choroiditis  posterior,  we  often 
notice  that  the  conjunctiva  becomes  flushed  if  they  persist  long  in 
reading,  sewing,  etc.  Again,  we  frequently  meet  with  the  same  thing  in 
persons  suffering  from  hypermetropia,  who  either  do  not  use  spectacles 
at  all,  or  of  an  insufficient  power,  so  that  their  accommodation  is  strained 
and  fatigued. 

It  may  also  be  caused  by  an  irritating  condition  of  the  atmosphere, 

e.g.,  cold  wind,  dust,  etc.     Or  it  may  be  due  to  mechanical  iiTitants, 

such  as  a  foreign  body  lodged  under  the  eyelids  or  in   the  cornea, 

inversion  of  the  lashes,  or  an  obstruction  of  the  lachrymal  passages. 

The  treatment  of  hypex'semia  of  the  conjunctiva  is  very  simple,  and 


16  DISEASES  OF  THE  CONJUNCTIVA. 

should  be  cldefly  directed  to  the  removal  of  the  cause.  If  it  be  brought 
on  by  overwork,  cessation  from  this  must  be  enforced,  and  if  the  patient 
suffers  from  hypermetropia,  this  must  be  treated  by  the  proper  use  of 
spectacles.  The  eye-douche  or  the  pulverizer  must  be  frequently  used, 
and  the  eyelids  should  be  bathed  with  an  evaporating  lotion,  which 
greatly  relieves  the  feeliug  of  heaviness  in  the  lids.  The  following 
lotions  will  be  found  very  useful  for  this  purpose  : — 

1.  51  Sp.  ^ther.  ISTit.  5j,  Acet.  Aromat.  gtts.  vj,  Aq.  Distill  ^yj.  To 
be  sponged  over  the  closed  eyelids  and  around  the  eyes  3 — 4  times 
daily,  and  allowed  to  evaporate. 

2.  '^  ^theris  ^ij — 5iv.  Spir.  Rosismar,  3iv.  To  be  used  in  the 
same  way  as  the  above,  but  in  smaller  quantity,  especially  if  the  skin 
be  very  delicate  and  susceptible.  The  best  astringent  lotions  are  those 
composed  of  2 — 4  grains  of  sulphate  of  zinc  or  acetate  of  lead,  in  4 — 6 
ozs.  of  water.  A  piece  of  folded  lint  saturated  with  tliis  lotion,  is  to 
be  laid  over  the  eyelids  for  15  or  20  minutes  several  times  a  day, 
and  a  few  drops  may  be  allowed  to  enter  the  eye. 

But  if  the  hypersemia  has  become  chronic,  these  applications  will 
not  suffice,  and  it  will  then  be  necessary  to  apply  a  drop  or  two  of  a 
weak  collyrium  (gr.  j. — ij.  to  5J.  of  water)  of  sulphate  of  zinc  or  copper, 
or  even  of  the  nitrate  of  silver,  to  the  conjunctiva;  or  the  sulphate  of 
copper  or  the  lajDis  divinus*  may  be  lightly  applied  in  substance.  The 
eye-douche  or  cold  compresses  should  be  used  after  these  applications. 
I  must  here  call  attention  to  a  very  prevalent  popular  error,  namely, 
that  it  strengthens  the  eyes  to  dip  the  face  into  cold  water  with  the 
eyelids  open.  This  habit  is,  however,  to  be  condemned,  as  it  often 
produces  much  irritation  and  hyperemia  of  the  conjunctiva. 


2.— CATARRHAL  OPHTHALMIA. 

The  term  "  simple  conjunctivitis  "  should,  I  think,  be  altogether 
discarded.  It  is,  in  fact,  only  the  mildest  form  of  catarrhal  ophthalmia, 
and  hence  there  is  no  reason  to  make  it  a  distinct  disease. 

On  everting  the  eyelids  in  a  case  of  catarrhal  ophthalmia,  we  notice 
that  the  conjunctiva  is  red,  vascular,  and  swollen,  so  that  the  Meibomian 
glands  are  nearly  or  entirely  hidden.  The  hyperasmia  commences  at  the 
tarsal  portion  of  the  conjunctiva,  to  which  it  may  indeed  remain  con- 
fined in  very  mild  cases.  Generally,  however,  it  soon  extends  to  the 
retro-tarsal  fold,  caruncle,  semilunar  fold,  and  ocular  conjunctiva, 
reaching  perhaps  quite  up  to  the  edge  of  the  cornea.  As  the  disease 
subsides  the  vascularity  retraces  its  steps  in  the  reverse  direction.     It  is 

*  Lapis  divinus  is  composed  of  equal  parts  of  sulphate  of  copper,  uitrate  of  potass 
and  alum,  which  ingredients  are  to  be  moulded  into  sticks. 


CATARRHAL   OPHTHALMIA.  17 

important  to  distinguish  the  vascularity  of  the  ocular  conjunctiva  from 
that  of  the  subconjunctival  tissue.*  The  former  is  characterised  by  a 
superficial  network  of  vessels  of  a  brick-red  or  scarlet  colour,  which  run 
up  to  the  edge  of  the  cornea,  and  are  freely  movable  upon  the  scle- 
rotic. The  meshes  of  this  network  are  coarse  and  large,  more  espe- 
cially towards  the  region  of  the  retro-tarsal  fold.  On  and  between  them 
are  often  noticed  coarse  red  patches  of  extra vasated  blood,  particularly 
near  the  cornea.  But  these  effusions  are  also  seen  on  the  palpebral 
conjunctiva  and  retro-tarsal  fold.  If  the  ocular  conjunctiva  is  alone 
implicated,  the  wliite  sclerotic  can  be  seen  shining  through  the  vascular 
meshes.  But  it  is  different  if  the  subconjunctival  tissue  is  also  injected, 
for  we  then  notice  fine,  parallel  vessels  of  a  rosy  tint,  radiating  towards 
the  cornea,  around  which  they  form  a  pink  zone.  These  vessels  are  not 
movable  upon  the  sclerotic. 

The  eyelids  are  generally  somewhat  swollen  and  red,  and  their  tem- 
perature is  perhaps  slightly  increased ;  but  none  of  these  symptoms  are 
so  marked  as  in  purulent  ophthalmia.  Occasionally  the  oedema  of  the 
eyelids  is  so  considerable,  that  the  upper  lid  hangs  down  in  a  massive 
fold,  and  overlaps  the  lower.  The  edges  of  the  lids  are  usually  some- 
what red  and  swollen,  and  at  a  later  stage  they  often  become  sore  and 
excoriated  from  the  discharge,  and  the  altered  secretion  of  the 
Meibomian  glands.  Indeed,  this  irritation  may  in  time  give  rise  to 
marginal  blepharitis. 

The  degree  of  swelling  of  the  lids  does  not,  however,  necessarily 
correspond  to  the  intensity  of  the  disease,  or  the  redness  of  the  con- 
junctiva. Thus,  in  feeble  subjects  we  sometimes  find  that  there  is  great 
oedema  of  the  lids,  leading  us  to  suspect  a  severe  form  of  the  disease, 
and  yet,  on  opening  the  eye,  we  are  surprised  to  find  but  slight  injection 
of  the  palpebral  and  ocular  conjunctiva,  and  but  little,  if  any,  discharge. 
In  such  cases  we  should  examine  as  to  the  existence  of  an  hordeolum, 
or  whether  the  patient  has  been  stung  on  the  lid  by  an  insect. 

In  the  severer  cases  of  catarrhal  ophthalmia,  we  find  that  the  con- 
junctiva becomes  very  swollen,  more  especially  in  the  region  of  the 
retro-tarsal  fold,  so  that,  on  considerable  eversion  of  the  eyelids,  it 
springs  into  view  in  the  form  of  one  or  more  tliick  red  girdles  encircling 
the  eyeball.     The  canincle  and  semilunar  fold  are   also  swollen,  and 

*  We  may  distinguish  three  kinds  of  vascidarity  on  the  eyeball :  1.  The  con- 
junctival vessels,  which  are  brick-red,  large-meshed,  and  freely  movable.  They  consist 
both  of  veins  and  arteries.  2.  The  subconjunctival  vessels  which  are  of  a  pink,  rosy 
tint,  their  meshes  being  smaller,  and  the  vessels  radiating  in  a  parallel  direction 
towards  the  edge  of  the  cornea,  around  which  they  form  a  rosy  zone ;  these  vessels 
are  chiefly  venous.  3.  The  sclerotic  vessels,  which  do  not  appear  in  the  form  of 
distinct  individual  vessels,  but  as  small  ill-defined  red  patches,  which  lend  a  bluish- 
red  blush  to  the  surface  of  the  sclerotic.  For  further  information  as  to  the  blood- 
vessels of  the  eye,  I  must  refer  the  reader  to  Leber's  important  researches,  A.  f.  O. 
li,  1,  1 ;  and  also  to  those  of  Bonders,  Klin.  Monatsblat.  1864. 

C 


18  •  DISEASES   OF   THE   CONJUNCTIVA. 

assume  a  dark  red  and  fleshy  appearance.  At  an  early  stage  of  the 
affection,  the  swelling  of  the  conjunctiva  is  firm,  and  lends  a  peculiar 
lustrous  and  glistening  appearance  to  the  inner  surface  of  the  lids ;  but 
later  it  becomes  more  flaccid  and  soft,  and  falls  more  readily  into  folds. 
The  papillse  of  the  conjunctiva  generally  become  swollen  and  turgid, 
often  to  a  considerable  degree,  so  that  they  give  a  rough,  velvety,  and 
so-called  "granular"  appearance  to  the  conjunctiva.*  In  severe  cases, 
especially  in  old  decrepid  persons,  and  after  the  long- continued  use  of 
cold  applications,  the  ocular  conjunctiva  may  also  become  swollen 
(chemosis),  which  is  due  to  a  seroiis,  or  perhaps  even  plastic,  infiltra- 
tion of  the  conjunctiva  and  subconjunctival  tissue.  In  the  majority 
of  cases,  however,  the  chemosis  is  but  very  slight. 

The  discharge  varies  in  quantity  and  quality,  according  to  the 
stage  and  intensity  of  the  affection.  In  the  early  stages,  there  is  gener- 
ally only  an  increased  secretion  of  tears,  but  the  discharge  soon  becomes 
more  opaque  and  stringy,  and  of  a  yellowish  red  tinge,  consisting  chiefly 
of  albumen  and  broken  down  epithelial  cells.  As  the  disease  advances, 
and  the  inflammatory  symptoms  increase  in  severity,  the  discharge 
becomes  more  copious  and  of  a  muco-purulent  character,  the  pus  cells 
being  suspended  in  the  mucus.  It  then  also  assumes  a  light  yellow 
colour,  and  a  thicker  and  more  creamy  consistence.  In  very  mild  cases 
it  is  often  so  sHght  in  quantity  that  it  might  easily  escape  detection. 
Perhaps  it  is  only  on  very  considerable  eversion  of  the  lids  that  a  thin 
yellow  string  of  matter  is  observed  to  be  embedded  and  almost  hidden 
in  the  folds  of  the  conjunctiva,  or  collected  in  the  form  of  a  small  yellow 
bead  at  the  angle  of  the  eye.  The  lashes  are  generally  found  to  be 
somewhat  glued  together  in  the  morning  by  the  discharge,  and  the 
altered  and  increased  secretion  of  the  Meibomian  glands. 

There  is  generally  very  little  pain  in  catarrhal  ophthalmia.  The 
patient  only  complains  of  a  feeling  of  heat  and  itching  in  the  lids  which 
causes  him  to  rub  them  frequently.  These  sensations  increase  towards 
night,  and  manifest  themselves  especially  during  reading  or  writing  by 
artificial  light,  or  in  a  crowded  and  smoky  room.  The  eyelids  feel  stiff 
and  heavy,  so  that  it  is  difficult  to  open  them,  this  is  especially  the  case 
if  the  lids  are  rather  tight  and  press  upon  the  globe.  One  of  the  most 
characteristic  symptoms  is  the  sensation  as  if  a  foreign  body,  such  as 
sand,  grit,  or  finely-powdered  glass  were  lodged  under  the  lids.  This  is 
evidently  due,   as  was  pointed  out  by  Mackenzie,   to  the  friction   of 

*  In  using  the  term  "granular"  for  tliis  appearance  of  the  conjunctiva,  I  must 
strongly  insist  upon  the  great  necessity  of  not  confounding  this  condition  with  that 
of  true  granular  lids,  which  is  but  too  often  done,  and  which  has  led  to  very  great 
confusion,  not  only  in  the  diagnosis,  but  also  in  the  treatment  recommended  for  these 
affections.  In  the  former  case,  the  granular  appearance  is  simply  due  to  the  infil- 
trated and  turgid  condition  of  the  papillae,  whereas  the  true  granulations  are  a  new 
formation  of  a  perfectly  diircrent  character. 


CATARRHAL  OPHTHALMIA.  19 

the  swollen  papilla)  against  the  ocular  conjunctiva.  This  sensation 
should,  however,  remind  us  of  the  fact  that  the  symptoms  of  catarrhal 
ophthalmia,  viz.,  conjunctival  and  subconjunctival  injection,  lachryma- 
tion,  pain,  &c.,  may  be  produced  by  a  foreign  body,  and  the  inner  sur- 
face of  both  lids,  as  well  as  the  cornea,  should  therefoi-e  be  carefully 
examined,  in  order  that  we  may  ascertain  whethej;"  a  foreign  body  be 
present  or  not. 

There  is  generally  only  a  slight  degree  of  photophobia.  If  it  is 
severe,  and  accompanied  by  much  lachrymation,  subconj  anctival  injec- 
tion, and  considerable  pain  in  and  around  the  eye,  more  particularly 
over  the  brow  and  down  the  side  of  the  nose  (ciliary  neuralgia),  it  is  a 
sign  that  there  is  much  irritation  of  the  ciliary  nerves. 

Vision  is  only  in  so  far  affected,  that  objects  may  appear  somewhat 
hazy  and  indistinct,  as  if  seen  through  ground  glass,  which  is  due  to 
the  presence  of  a  little  of  the  discharge  upon  the  cornea.  The  patients 
also  notice  muscjB  voHtantes  in  the  shape  of  strings  of  fine  beads  float- 
ing through  the  field  of  vision,  these  are  produced  by  mucus  and  little 
flakes  of  epithelium  being  washed  over  the  cornea  by  the  movements  of 
the  eyelids.  For  the  same  reason,  the  flame  of  a  candle  often  appears  to 
be  surrounded  by  a  coloured  ring  which,  however,  also  disappears  when 
the  lids  are  riibbed.  I  need  hardly  point  out  that  this  should  not  be 
confounded  with  the  luminous  ring  round  a  flame,  which  is  one  of  the 
premonitory  symptoms  of  glaucoma. 

Catarrhal  ophthalmia  may  be  caused  by  sudden  changes  in  the 
atmosphere,  by  exposure  to  cold,  di'aught,  and  wet,  or  to  great  heat  and 
glare,  as,  for  instance,  from  a  blacksmith's  forge,  or  a  large  cooking  fire. 
Long  confinement  in  hot,  smoky,  crowded,  and  ill- ventilated  rooms  may 
likewise  produce  it,  as  also  excessive  use  of  the  eyes,  especially  by  arti- 
ficial light.  Or  it  may  show  itself  in  conjunction  with,  and  be  a  part 
symptom  of  the  aflections  of  the  mucous  membrane  of  the  nose  or 
respiratory  organs.  As  a  continuation  of  the  common  integument,  the 
conjunctiva  may,  moreover,  become  affected  in  the  acute  exanthemata, 
as  in  small  pox,  scarlatina,  and  measles,  also  in  erysipelas,  herpes  zoster, 
and  eczema  of  the  face.  It  may  suffer  consecutively  in  affections  of  the 
eyelids,  as  for  instance  in  ectropion  or  distichiasis,  or  in  those  of  the 
lachrymal  apparatus.  Indeed  epiphora  dependent  upon  some  impedi- 
ment to  the  free  efilux  of  the  tears,  is  a  not  unfrequent  cause  of  obstinate 
and  chronic  inflammation  of  the  conjunctiva,  which  readily  disappears  as 
soon  as  the  lachrymal  affection  is  ciu'ed.  Undetected  foreign  bodies,  or 
injuries  from  mechanical  or  chemical  irritants  may  also  give  rise  to  con- 
junctivitis. 

Finally,  it  may  be  produced  by  contagion,  more  especially  if  the 
disease  is  at  all  severe,  if  the  swelhng  extends  to  the  retro-tarsal  fold  of 
the  upper  lid  and  the  discharge  is  of  a  muco-purulent  character.    It 

c  2 


20  DISEASES   OF   THE   CONJUNCTIVA. 

almost  always  reproduces  catarrhal  oj^htlialmia  and  only  in  rare  cases 
gives  rise  to  the  pm^ulent  or  diphtheritic  form. 

The  prognosis  of  catarrhal  ophthalmia  is  favom^ahle,  for  the  affec- 
tion is  very  amenable  to  treatment.  The  milder  forms  generally  run 
their  course  in  a  few  days,  the  more  severe  in  two  or  three  weeks.  The 
cornea  becomes  but  seldom  implicated,  and  even  if  ulcers  should  form 
upon  it,  they  are  generally  quite  superficial  and  peripheral,  so  that  at 
the  worst  they  only  give  rise  to  a  slight  opacity.  Only  in  very  severe 
cases  and  under  very  injudicious  treatment  do  the  cornea  and  iris  par- 
ticipate, to  any  dangerous  extent. 

If  the  affection  is  neglected,  it  may  become  chronic  and  prove  very 
obstinate  and  intractable,  more  especially  in  old  persons.  The  conjunc- 
tiva becomes  flaccid  and  rough,  and  this  may  give  rise  to  superficial 
corneitis,  or  ectropion,  particularly  of  the  lower  lid. 

The  treatment  must  vary  according  to  the  stage  and  the  severity 
of  the  disease.  If  the  eye  is  very  irritable,  and  there  is  much  photo- 
phobia, lachrymation  and  ciliary  neuralgia,  accompanied  by  conjunc- 
tival and  marked  subconjunctival  injection,  astringent  lotions  should 
be  carefully  avoided,  as  they  would  increase  the  irritability,  or  might 
even  set  up  inflammation  of  the  cornea  or  iris.  In  such  cases,  the  lids 
should  be  well  everted  and  a  careful  examination  made  as  to  the  presence 
of  a  foreign  body  beneath  them,  or  upon  the  cornea.  If  none  is  detected, 
the  condition  of  the  palpebral  and  ocular  conjunctiva,  and  of  the  cornea 
and  iris  should  next  be  ascertained,  as  these  symptoms  of  irritation  may 
be  due  to  phlyctenular  ophthalmia,  or  to  a  commencing  inflammation  of 
the  cornea  or  iris.  In  this  condition  of  the  eye,  it  is  often  impossible 
to  decide  whether  it  is  simply  a  case  of  commencing  catarrhal  ophthal- 
mia accompanied  by  unusually  severe  symptoms  of  ciliary  irritation,  or 
whether  it  is  a  case  of  incipient  corneitis  or  iritis.  It  is,  therefore, 
always  the  wisest  plan  to  leave  the  question  of  diagnosis  open,  until  the 
real  character  of  the  affection  becomes  more  pronounced,  and  to  en- 
deavour to  alleviate  the  symptoms  of  irritation  by  soothing  applications. 
By  so  doing,  we  guard  ourselves  against  committing,  perhaps,  a  serious 
error  in  treatment.  For  if  it  should  turn  out  to  be  a  case  of  catarrhal 
ophthalmia,  astringents  may  be  employed  as  soon  as  the  symptoms  of 
irritation  have  somewhat  subsided,  and  the  discharge  has  assumed  a 
muco-purulent  character ;  if,  on  the  other  hand,  it  should  prove  to  be  a 
case  of  corneitis  or  iritis,  the  treatment  has  been  most  appropriate  and 
judicious,  whereas  the  use  of  astringents,  more  especially  the  more 
powerful  ones,  would  have  been  very  injurious. 

The  patient  should  be  warned  to  guard  his  eyes  against. exposure  to 
wet  or  cold;  and  to  abstain  from  all  reading,  &c.,  more  especially  by 
artificial  light. 

In  order   to  relieve  the  ciliary  neuralgia,  hot  poppy  fomentations 


CATARRHAL   OPHTHALMIA.  21 

should  be  applied  to  the  eye  ;  but  if  the  patient  should  be  of  a  rheumatic 
habit,  the  moisture  may  produce  considerable  oedema  of  the  lids,  and, 
hot  dry  flannels  are  therefore  to  be  preferred. 

A  solution  of  atropine  (gr.  ij  to  3J  of  water)  should  be  dropped  into 
the  eyes  two  or  three  times  a-day,  and  the  following  compound  bella- 
donna ointment  should  be  rubbed  over  the  forehead : — 

$1  Extract  Belladonnas  gr.  x. — Hydrarg.  Ammon.  Chlorid.  gr.  v. — 
Adip.  5j.  M.  A  portion  of  this  is  to  be  rubbed  over  the  forehead  three 
or  four  times  daily,  and  should  be  covered  by  a  piece  of  thin  tissue 
paper,  so  as  to  prevent  its  drying  and  becoming  hard.  It  should  not  be 
washed  off  until  it  is  time  for  its  re-application.  In  the  course  of  two 
or  three  days  a  slight  papular  eruption  will  appear,  when  the  ointment 
is  to  be  discontinued. 

When  the  acute  symptoms  of  ii'ritation  have  subsided,  and  those  of 
catarrhal  ophthalmia — more  especially  a  muco-pui-ulent  discharge — 
begin  to  show  themselves,  astringents  must  be  applied.  In  the  milder 
cases,  in  which  there  is  not  much  conjunctival  redness,  and  the  discharge 
is  chiefly  of  a  mucous  character,  lodging  in  the  form  of  thin,  yellowish 
stringy  flakes  in  the  retro-tarsal  fold,  or  the  angles  of  the  eye,  a  solution 
of  sulphate  of  zinc  or  copper  (1  or  2  grains  to  the  ounce  of  distilled 
water)  should  be  dropped  into  the  eye  two  or  three  times  daily.  If  the 
blood  vessels  are  mach  dilated,  and  the  conjunctiva  relaxed  and  flaccid, 
a  solution  of  tannin  (gr.  iv — viij  to  3J  of  water)  is  to  be  preferred.  I 
have  also  found  much  benefit  from  the  chloride  of  zinc  (gr.  ss — j  to  ^j) 
which  is  strongly  recommended  by  Mr.  Critchett. 

But  if  the  inflammation  is  severe,  if  the  discharge  is  copious,  thick, 
and  creamy,  these  remedies  will  no  longer  sufiice,  and  we  must  have 
recourse  to  the  nitrate  of  silver,  the  strength  of  the  solution  varying 
according  to  the  amount  and  thickness  of  the  discharge.  For  general 
pui'poses  a  solution  of  2  or  3  grains  to  the  ounce  will  be  found  the  best. 
A  large  drop  of  this  should  be  applied  with  a  camel's  hair  brush  or  a 
quill  to  the  inside  of  the  lower  eyelid  three  or  four  times  a-day.  The 
lids  should  then  be  rubbed  with  the  finger,  so  that  the  solution  may 
come  in  contact  with  the  whole  of  the  conjunctiva.  The  feehng  of  grit 
and  sand  in  the  eye  as  well  as  the  lachrymation  are  much  relieved,  and 
will  disappear  for  five  or  six  hours.  On  their  reappearance,  the  collyrium 
should  be  again  applied.  It  may,  however,  be  necessary  to  apply  a 
still  stronger  solution  (gr.  iv — vj  to  5j)  if  the  discharge  is  very 
copious  and  thick,  and  if  the  afiection  has  lasted  for  some  time.  Before 
the  collyrium  is  applied,  the  discharge  must  be  removed  by  the  injection 
of  lukewarm  water  beneath  the  lids.  This  renders  the  action  of  the 
collyrium  far  more  efficacious.  After  each  instillation  of  the  astringent 
coUyria,  cold  water  compresses  should  be  applied  to  the  hds  for  the 
space  of  from  a  quarter  to  half  an  hour,  being  changed  as  soon  as  they 


22  DISEASES   OF   THE   CONJUNCTIVA. 

become  at  all  warm.     This  will  give  great  relief  to  the  patient,  and 
snbdue  the  pain  and  ii'ritation  produced  by  the  lotion. 

Lukewarm  water  shonld  be  injected  between  the  lids  every  two  or 
three  hours  so  as  to  wash  away  the  discharge.  Or  the  following  lotion 
recommended  by  Mackenzie  may  be  employed  with  advantage  for  this 
purpose.  9=  Hydrarg.  Bichlorid.  gr.  j. — Ammonia  Muriat.  gr.  vj. — ^Aq. 
distill,  ^vj. — Misce.  A  table- spoonful  of  this  lotion  is  to  be  mixed  with  a 
table-spoonful  of  hot  water.  In  mild  cases  the  eyes  should  be  fomented 
with  it  three  or  four  times  daily,  a  little  being  permitted  to  enter  the  eye. 
In  severer  cases  it  should  be  injected  over  the  whole  conjunctiva. 

A  little  simple  cerate  or  unscented  cold  cream  is  to  be  applied  to  the 
edges  of  the  lids  to  prevent  theii'  sticking.  If  crusts  have  formed  upon 
the  lashes,  they  are  to  be  soaked  with  warm  water,  and  then  carefully 
removed  so  as  not  to  produce  any  excoriation.  If  the  edges  or  angles  of 
the  lids  are  sore  and  excoriated,  the  red  precipitate  ointment  (gr.  j — ij 
to  the  drachm  of  lard)  is  to  be  applied  night  and  morning,  or  the  weak 
nitrate  of  mercury  ointment  may  be  used. 

The  attendants  must  be  warned  that  the  discharge  in  catarrhal 
ophthalmia  is  contagious,  and  that  the  sponges,  towels,  &c.,  used  for 
the  patient  must  be  carefully  kept  apart,  and  not  employed  for  any- 
other  purpose.  Some  authors  have  expressed  a  doubt  as  to  the  con- 
tagiousness of  catarrhal  ophthalmia,  but  in  out-patient  practice  we  have 
very  frequent  opportunities  of  seeing  several  members  of  the  same  family 
affected  consecutively  with  the  disease.  Constitutional  treatment  will 
hardly  be  required ;  the  bowels  should  be  kept  freely  open  and  if  the 
patient  is  feeble  and  out  of  health,  tonics  should  be  administered. 


3.— PURULENT    OPHTHALMIA. 

(Syn.  Egyptian  ophthalmia,  contagious  ophthalmia,  military  oph- 
thalmia.) 

We  cannot  di-aw  a  sharp  line  of  demarcation  between  acute 
catarrhal,  and  piu-ulent  ophthalmia.  The  latter  may  indeed  be 
regarded  as  a  more  severe  form  of  catarrhal  ophthalmia,  in  which 
all  the  symptoms  of  this  affection  are  intensified  in  degree.  The  lids 
are  more  cedematous,  hot,  and  red,  the  palpebral  and  ocular  conjunc- 
tiva more  injected  and  swollen,  and  the  papilla3  more  tm'gid  and 
prominent.  The  chemosis  is  also  more  considerable,  and  the 
dischai'ge  is  thicker,  more  copious,  and  more  contagious.  The  inflamma- 
tion is,  moreover,  not  confined  to  the  conjunctiva,  but  extends  deeper, 
and  involves  also  the  sub-conjunctival  tissue.  So  that  there  is  not  only 
a  secretion  of  muco-purulent  discharge  upon  the  free  surface  of  the 
conjunctiva,  but  also  an   infiltration   of  sero-plastic  lymph   into   the 


PURULENT   OPHTHALMIA.  23 

substance  of   this   membrane.       The    cornea   is,    moreover,    far   more 
frequently  and  more  seriously  implicated  than  in  catarrhal  ophthalmia. 

At  the  commencement,  the  patient  experiences  a  sensation  of  heat 
and  itcliing  in  the  eye,  as  if  a  foreign  body,  more  especially  sand  or 
grit,  were  lodged  beneath  the  eyelids.  The  edges  of  the  latter  become 
slightly  glued  together,  and  small  beads  of  matter  collect  and  harden 
on  the  lashes  and  at  the  corners  of  the  eye.  On  eversion  of  the  lids, 
their  lining  membrane  is  found  to  be  very  vascular,  swollen,  and  of  a 
uniform  redness,  so  that  the  Meibomian  glands  can  no  longer  be  dis- 
tinguished. The  retro-tarsal  fold,  the  caruncle,  semilunar  fold,  and 
ocular  conjunctiva  are  also  abnormally  red  and  swollen.  The  eyelids 
are  red,  glistening,  and  perhaps  somewhat  puffy.  At  first,  there  is  only 
considerable  lachrymation,  but  the  discharge  soon  assumes  a  muco- 
purulent character,  having  yellow  flakes  of  pus  and  broken-down 
epithehal  cells  suspended  in  it. 

Up  to  this  point,  all  these  symptoms  are  only  those  of  catarrhal 
ophthalmia.  But  as  the  disease  advances,  they  soon  become  more 
severe  in  character.  The  patient  often  experiences  great  pain  in  and 
around  the  eye,  which  may  even  extend  to  the  corresponding  half  of 
the  head,  especially  if  the  inflammation  be  of  a  sthenic  character,  in 
which  case  marked  febrile  symptoms  may  also  present  themselves. 
Generally,  the  pain  diminishes  as  soon  as  the  discharge  becomes 
purulent.  It  may,  however,  again  increase  in  severity  if  the  cornea 
becomes  affected,  and  especially  if  the  iris  or  other  tissues  of  the  globe 
should  become  involved  in  the  inflammation.  In  general  inflammation 
of  the  eye-ball  (panophthalmitis)  the  pain  is  often  excruciating. 

The  laclii'ymation  and  photophobia  increase,  the  lids  become  very 
swollen,  so  that  the  upper  hangs  down  in  a  thick  heavy  fold,  and  they 
can  only  be  opened  or  everted  with  difficulty.  They  are  red,  glistening, 
and  cedematous,  and,  if  deeply  pressed,  somewhat  tender.  Their  tem- 
perature, though  markedly  increased,  never  reaches  a  very  high  degree, 
and  this,  together  with  the  absence  of  tenderness,  is  of  importance  in 
the  differential  diagnosis  between  purulent  and  diphtheritic  ophthalmia. 
The  conjunctiva  becomes  vascular  and  swollen,  and  patches  of  effused 
blood  are  noticed  both  on  its  palpebral  and  ocular  portion.  The 
papillae  are  very  tui-gid  and  prominent,  giving  a  rough  and  villous 
appearance  to  the  inside  of  the  lids.  As  they  increase  in  size  they 
become  flattened  at  the  sides,  from  being  pressed  against  each  other, 
and  they  appear  arranged  in  rows  without  a  distinct  base.  The  pro- 
minence may  be  so  considerable  that  they  assume  the  appearance  of 
cauliflower  excrescences.  They  often  bleed  freely  on  the  sh'ghtest 
touch,  as  their  epithelial  covering  is  very  thin  and  easily  shed.  The 
retro-tarsal  fold  is  much  swollen,  and,  on  eversion  of  the  lids,  springs 
into  view   in   the  form   of  thick,    red,   fleshy  girdles  which   encircle 


24  DISEASES   OF   THE   CONJUNCTIVA. 

the  eye-ball.  The  ocular  conjunctiva  becomes  very  vascular,  and  a 
serous  or  even  plastic  effusion  takes  place  into  it  and  the  sub-con- 
junctival  tissue.  This  chemosis  is  far  more  marked  than  in  catarrhal 
ophthalmia,  and  may  be  so  considerable  as  to  rise  like  a  high,  red, 
semi-transparent  mound  round  the  cornea,  overlapping  its  edges  more 
or  less  considerably,  and  even  perhaps  protruding  between  the  lids. 
The  chemosis  is  most  prominent  at  the  outer  and  inner  side  of  the 
cornea,  at  the  triangular  spaces  opposite  the  palpebral  aperture  ;  for 
the  pressure  of  the  lids  keeps  down  the  chemotic  swelling  above  and 
below.  On  account  of  the  great  swelling  and  weight  of  the  eyelids, 
and  the  great  chemosis,  the  vessels  supplying  the  cornea  become  much 
compressed  and  its  nutrition  proportionately  impaired  ;  and  this  explains 
the  great  tendency  to  ulceration  and  suppuration  of  the  cornea  in  severe 
purulent  ophthalmia.  For  the  idea  that  the  irritating  and  noxious 
character  of  the  discharge  produces  the  affection  of  the  cornea  is 
erroneous. 

As  the  disease  advances,  the  discharge  increases  in  quantity,  becomes 
more  opaque,  thick,  and  creamy,  and,  on  account  of  its  admixture  with 
blood,  frequently  assumes  a  reddish  yellow  tint.  It  is  often  so  con- 
siderable in  quantity  that  it  wells  out  from  between  the  eyelids  when 
these  are  opened  and  flows  down,  over  the  cheek ;  the  lashes  become 
clogged  with  it,  and  glued  together  into  httle  bundles.  It  collects  in 
the  retro-tarsal  fold  and  on  the  surface  of  the  cornea  in  the  hollow 
formed  by  the  chemosis,  and  this  appearance  may  easily  be  mistaken 
by  a  superficial  observer  for  suppuration  of  the  cornea.  The  discharge 
should,  therefore,  always  be  wiped  away  from  the  cornen.  before  any 
opinion  is  formed  as  to  the  condition  of  the  latter.  On  cleansing  away 
the  matter  from  the  surface  of  the  palpebral  conjunctiva,  we  notice 
that  the  latter  looks  red,  glistening,  villous,  and  succulent,  which 
enables  us  at  a  glance  to  distinguish  the  disease  from  diphtheritic 
conjunctivitis.  Sometimes,  however,  the  discharge  is  more  tenacious 
and  clings  to  the  surface  of  the  conjunctiva  like  a  thin  membrane,  so 
that  it  cannot  be  easily  wiped  away,  but  requires  to  be  stripped  off, 
when  it  comes  off  in  the  form  of  thin  flakes.  But  on  its  removal,  we 
find  that  the  membrane  was  quite  superficial,  and  that  the  appear- 
ance of  the  conjunctiva  beneath  is  the  same  as  that  described  above. 
Hence  it  is  erroneous  to  call  this  diphtheritic  conjunctivitis,  simply 
because  the  discharge  is  more  tenacious  and  comes  off  in  flakes,  for  the 
symptoms  of  true  diphtheritic  ophthalmia  are  not  only  very  different, 
but  demand  a  very  different  course  of  treatment.  There  can  be  no 
objection,  however,  to  terming  it  "  membranous  ophthalmia."  We 
sometimes,  however,  meet  with  mixed  forms  of  purulent  and  diph- 
theritic ophthalmia. 

The  chief  danger  in  purulent  ophthalmia  is  the  implication  of  the 


PURULENT   OPHTHALMIA.  25 

cornea.  Any  cloudiness  of  the  latter  must,  therefore,  be  always 
regarded  as  an  untoward  symptom,  more  especially  if  it  already  shows 
itself  at  an  early  stage  of  the  disease,  and  if  there  is  any  tendency  to 
a  diphtheritic  character  in  the  ophthalmia.  At  a  later  period  it  is  less 
to  be  feared.  The  appearance  of  the  cornea  must  be  carefully  watched 
from  day  to  day,  and  in  severe  cases  its  condition  should  be  examined, 
if  possible,  at  the  interval  of  a  few  hours.  Implication  of  the  cornea 
is  especially  likely  to  occur  if  the  inflammation  is  very  severe,  the 
temperature  of  the  lids  much  increased,  the  chemosis  considerable  and 
fii-m,  and  accompanied  by  great  photophobia,  lachrymation,  and  ciliary 
neui'algia.  The  pain  is  generally  intermittent,  and  often  very  severe 
especially  towards  night ;  it  may  extend  deep  into  the  oi'bit  and  over 
the  corresponding  side  of  the  head  and  face.  On  examining  the  condi- 
tion of  the  cornea  we  may  then  perhaps  discover  small  phlyctenule  at  its 
edge  or  upon  its  surface,  which  soon  pass  over  into  ulcers.  Sometimes 
there  is  a  serous  infiltration  (oedema)  into  the  cornea  which  may  remain 
confined  to  the  periphciy,  giving  it  a  slightly  steamy  or  clouded 
appearance.  If  this  opacity  is  considerable,  and  extends  over  the 
centre  of  the  cornea,  the  sight  may  be  greatly  impaii'ed,  or  a  cu'cum- 
scribed  light  grey  infiltration  may  appear  at  one  portion  of  the  cornea 
and  disappear  again  as  the  ophthalmia  subsides,  or  it  may  become 
more  dense  and  assume  a  yellow  tinge.  Generally,  the  infiltration  soon 
changes  into  an  ulcer,  which  may  in  favourable  cases  remain  superficial 
and  ultimately  leave  only  a  very  slight,  or  even  no  opacity  of  the 
cornea.  But  if  the  infiltration  or  ulcer  is  of  considerable  size  and 
rather  deep,  a  dense  opacity  may  remain  behind,  and  greatly  impair 
the  sight  if  it  be  situated  in  the  centre  of  the  cornea.  The  ulcer, 
instead  of  remaining  superficial,  may,  however,  rapidly  increase  in 
circumference  and  depth,  and  soon  lead  to  extensive  perforation  of  the 
cornea,  accompanied  by  prolapse  of  the  iris,  escape  of  the  lens  and 
perhaps  of  a  portion  of  the  vitreous  humour,  and  be  followed  probably 
by  the  formation  of  a  considerable  staphyloma. 

When  the  cornea  gives  way,  the  patient  experiences  a  sudden 
remission  of  the  violent  pain,  accompanied  by  a  gush  of  fluid  over 
the  cheek.  If  the  ulcer  is  large,  the  cornea,  on  account  of  being 
thinned  and  softened  at  this  point,  may  become  somewhat  bulged 
forward  before  perforation  occurs.  The  dangerous  character  of  the 
ulcer  of  course  iacreases  with  its  extent,  as  the  perforation  will  be  pro- 
portionate in  size. 

Sometimes  several  infiltrations  are  formed  near  to  each  other  and 
then  coalesce,  thus  giving  rise  to  one  large  ulcer.  In  many  cases  the 
perforation,  if  it  be  but  of  limited  extent,  is  the  best  thing  that  can 
occur,  for  the  ulcer  instead  of  increasing  in  circumference,  then  begins 
at  once  to  heal. 


26  DISEASES   OF   THE   CONJUNCTIVA. 

Perforation  of  the  cornea  may  give  rise  to  tlie  following  complica- 
tions. 1.  Prolapse  of  tlie  iris.  2.  Anterior  synechia.  3.  Central 
capsular  cataract.  4.  Displacement  or  obliteration  of  the  pupil.  5.  An- 
terior staphyloma.  For  further  information  upon  this  subject,  I  must 
refer  the  reader  to  the  chapter  upon  ulcers  of  the  cornea. 

If  the  perforation  of  the  cornea  is  small,  a  little  portion  of  the  iris 
will  fall  against  it ;  when  the  aqueous  humour  escapes,  lymph  will  be 
effused  at  the  bottom  of  the  ulcer,  and  the  iris  will  become  adherent  at 
this  point  to  the  cornea,  giving  rise  to  an  anterior  synechia.  The  pupil 
will  be  dragged  towards  the  adhesion  and  more  or  less  displaced ;  or  it 
may  be  partially  or  wholly  implicated  in  it.  If  the  perforation  was 
extremely  small  (such  as  would  be  produced  by  a  fine  needle)  the 
re-accumulation  of  the  aqueous  humour  may  tear  tlu-ough  any  little 
adhesion  that  has  taken  place  between  the  iris  and  cornea,  and  no 
anterior  synechia  will  be  left.  When  the  perforation  occurs  at  the 
centre  of  the  cornea,  the  lens  will  come  in  contact  with  the  bottom  of 
the  ulcer,  and  a  central  anterior  capsular  cataract  may  be  formed.  If 
the  cornea  gives  way  to  a  greater  extent,  a  knuckle  of  iris  may  be 
pushed  into  the  ulcer  and  cause  a  prolapse  of  the  iris,  which  may 
increase  to  a  very  considerable  size  from  the  aqueous  humour  collecting 
within  it  and  swelling  it  out.  A  small  protrusion  of  this  kind  has  been 
termed  a  myoceplialon.  Or  the  lens  may  escape  together  with  a  portion 
of  the  vitreous  humour*,  if  the  ruptui'e  of  the  cornea  is  large,  and  then 
the  eyeball  may  become  atrophied.  Or  the  iris  falls  into  the  gap, 
becomes  adherent  to  the  cornea  and  covered  with  lymph,  which  assumes 
a  cicatricial  character,  and  yielding  gradually  to  the  intra-ocular  pressure, 
becomes  more  and  more  prominent,  and  a  partial  or  total  staphyloma 
results. 

A  very  dangerous  kind  of  ulcer  is  that  which  makes  its  appearance 
in  the  form  of  a  small  crescentic  ulcer  near  the  edge  of  the  cornea 
(generally  the  lower),  looking  as  if  it  had  been  scratched  by  a  finger 
nail.  Its  edges  soon  become  infiltrated  and  assume  a  yellow  tint.  It 
increases  in  depth,  and  rapidly  extends  further  and  further  round  the 
cornea  until  it  may  give  rise  to  a  very  considerable  perforation  or  slough 
of  the  cornea.  On  account  of  its  being  situated  so  closely  to  the  edge 
of  the  cornea,  this  form  of  ulcer  is  often  hidden  by  the  chemosis  and 
thus  easily  overlooked  at  the  outset. 

In  very  severe  cases  of  purulent  ophthalmia  with  intense  inflamma- 
tory symptoms,  sloughing  of  a  great  portion  or  even  of  the  whole  of 
the  cornea  may  take  place  within  a  few  hours.  The  cornea  loses  its 
transparency,  becomes  of  a  greyish  white  colour  which  soon  passes  into 
a  yellow  tint,  and  looks  shrivelled  and  quite  opaque.  It  soon  yields  to 
the  intra-ocular  pressure,  gives  way,  and  the  eyeball  becomes  atrophied. 

Iritis  may  supervene  when  the  ulceration  has  extended  to  the  deeper 


PURULENT   OPHTHALMIA.  27 

layers  of  the  cornea,  or  when  perforation  has  occurred.  If  severe,  it 
generally  gives  rise  to  great  ciliary  neuralgia,  photophobia,  and  lachrynaa- 
tion.  If  a  portion  of  the  cornea  remains  sufficiently  clear  to  permit  of  our 
seeing  the  iris,  we  find  the  latter  discoloured,  and  the  pupil  contracted, 
irregular,  and  perhaps  blocked  up  with  lymjDh,  or  there  may  be  pus  in 
the  anterior  chamber.  The  inflammation  may  extend  from  the  iris  to 
the  other  tissues  of  the  eye,  and  general  inflammation  of  the  eyeball 
(panophthalmitis)  set  in,  accompanied  by  excruciating  pain.  Pannus 
occurs  but  seldom  in  acute  purulent  ophthalmia,  and  only  in  cases 
where  the  papillae  have  been  much  swollen  from  the  very  commencement 
of  the  disease,  and  from  their  rubbing  against  the  cornea  have  induced 
a  supei-ficial  vascular  corneitis.  ■  It  is  more  frequently  met  with  in 
chronic  ophthalmia.  It  is  an  interesting  fact,  that  if  the  cornea  has 
been  sufiering  from  pannus  before  the  attack  of  purulent  ophthalmia, 
there  is  far  less  danger  of  its  ulcerating  or  suppurating  than  if  it  is 
quite  transparent.  This  important  fact  has  been  utilized  in  the  treat- 
ment by  inoculation  of  pannus  dependent  upon  granular  lids. 

Purulent  ophthalmia  generally  runs  its  course  in  three  or  four  weeks. 
It  may,  however,  become  chronic  and  last  for  many  months  or  even 
years,  and  prove  very  obstinate.  This  is  especially  the  case  if  the 
papillEe  remain  swollen  and  prominent,  for  by  their  constant  friction 
against  the  cornea,  pannus  is  but  too  often  produced.  The  relaxed 
condition  of  the  conjunctiva  may  also  give  rise  to  ecti'opion,  or  this 
may  be  produced  by  the  lids  having  become  everted  during  the  progress 
of  the  disease,  and  not  having  been  properly  replaced. 

Causes. — Purulent  ophthalmia  may  become  developed  from  an  acute 
catarrhal  ophthalmia,  by  the  symptoms  of  the  latter  increasing  in 
severity,  either  through  a  continuation  of  the  original  cause,  through 
neglect,  or  through  a  mistaken  course  of  treatment.  The  same  causes 
which  may  give  rise  to  catarrhal  ophthalmia,  viz.,  exposure  to  cold  or 
draught,  great  glare,  &c.,  may  also  produce  the  pm^ulent  form.  "We 
find  sometimes  that  it  occurs  epidemically,  and  that  mild  irritants, 
which  would  at  other  times  only  have  caused  a  simple  catarrhal  con- 
junctivitis, now  produce  purulent  ophthalmia.  An  unhealthy  locality, 
a  vitiated  atmosphere,  crowded  and  badly  ventilated  rooms,  exposure  to 
great  heat  or  cold,  dust,  and  glare,  intensify  the  character  of  the  epidemic. 
Some  of  these  causes  are  frequently  met  with  in  places  where  many 
persons  are  collected  together,  as  in  workhouses,  foundling  hospitals,  and 
large  barracks.  If  purulent  or  even  catarrhal  ophthalmia  once  breaks 
out  in  such  establishments,  it  is  often  very  difficult  to  arrest  it  before  it 
has  spread  widely  amongst  the  inmates  and  committed  great  ravages.  If 
soldiers  on  their  march  or  in  camp  are  exposed  to  great  heat  and 
glare,  and  to  hot  winds  carrying  before  them  clouds  of  sand  or  dust,  as 
occurs  in  India  or  Egypt,  ophthalmia  will  soon  show  itself  amongst 


28  DISEASES   OF   THE   CONJUNCTIVA. 

them.  Hence  the  terms  mihtary  and  Egyptian  ophthalmia.  These 
names  should,  however,  be  abandoned,  for  this  affection  shows  no  special 
characteristics  warranting  its  being  classed  as  a  disease  sui  generis. 
The  epidemic  is  in  such  cases  generally  one  of  purulent  ophthalmia,  but 
sometimes  it  may  assume  the  character  of  severe  catarrhal  or  granular 
ophthalmia.  Or  these  affections  may  pass  One  into  the  other,  or  exist 
side  by  side  in  the  same  army.  This  being  so,  we  can  easily  understand 
how  such  various,  and  often  conflicting  and  confused  accounts  have 
been  given  of  the  character,  the  severity,  and  the  contagiousness  of  the 
so-called  military  ophthalmia. 

Contagion  is  the  most  frequent  cause,  as  the  contagious  power  of 
the  discharge  is  often  very  great.  This  varies,  however,  according  to 
the  severity  and  stage  of  the  disease.  Piringer,*  who  made  a  great 
number  of  valuable  and  interesting  experiments  to  test  the  contagious 
power  of  the  discharge,  found  that  during  the  earliest  stage,  and  also  in 
chronic  cases,  in  which  the  discharge  is  thin,  watery,  and  transparent, 
it  is  hardly,  if  at  all,  contagious.  But  it  becomes  slightly  so  when, 
though  still  watery,  it  assumes  a  somewhat  muco-purulent  character, 
and  then  it  generally  reproduces  a  mild  form  of  the  disease.  The 
contagiousness  increases  in  proportion  to  the  intensity  of  the  disease, 
and  the  purulent  nature  of  the  discharge.  According  to  the  same 
authority,  the  discharge  of  a  severe  purulent  ophthalmia,  if  applied  to  a 
healthy  conjunctiva,  may  reproduce  the  disease  in  from  6 — 12  hours  ;  that 
from  a  moderately  severe  form  in  from  12 — 36  ;  the  mild,  in  60 — 70 ; 
and  that  from  chronic  ophthalmia  in  72 — 96  hours.  It  is  of  the  greatest 
practical  importance  to  remember  that  the  discharge  from  purulent 
ophthalmia  does  not  always  reproduce  the  purulent  form,  but  may  give 
rise  to  catarrhal,  granular,  or  even  diphtheritic  conjunctivitis.  Just  as 
the  discharge  from  catarrhal,  diphtheritic,  and  acute  granular  ophthal- 
mia may  produce  purulent  ophthalmia.  The  special  form  of  conjunctivitis 
which  may  arise,  will  depend  upon  atmospherical,  local,  and  constitu- 
tional causes,  and  also  upon  the  age  of  the  patient.  Thus  Von  Graefe 
states  t  tliat  in  Berlin  the  matter  from  ophthalmia  neonatorum,  when 
applied  to  the  eyes  of  children  of  two  or  three  years  of  age,  generally 
produces  diphtheritic  conjunctivitis,  whereas  when  applied  to  adults  it 
mostly  gives  rise  to  purulent  or  sometimes  to  granular  ophthalmia. 

Healthy  eyes  are  more  rapidly  and  severely  affected  by  the  inocula- 
tion of  contagious  matter  than  those  suffering  from  vascular  forms  of 
corneitis,  more  especially  pannus.  Repeated  inoculation  diminishes  the 
contagious  power  of  the  discharge.  This  is  also  diminished  by  diluting 
the  latter  with  water,  it  being  altogether  lost  when  it  is  diluted  mth 
about  one  hundred  parts  of  water.     Gonorrhoeal  and  vaginal  discharges 

*  Piringer  "  Die  Blennorhoe  im  Monschenauge,"  Gratz,  ].841. 
t  Deutsche  Klinik,  1864,  p.  79. 


PURULENT   OPHTHALMIA.  29 

may  also  produce  purulent  oplithalmia.  It  appears  certain  that  the  air 
is  often  a  carrier  of  the  contagion,  especially  if  many  persons  suffering 
from  severe  purulent  ophthalmia  are  crowded  together  in  one  room, 
and  this  is  perhaps  small  and  ill  ventilated.  Von  Graefe  thinks  that  in 
such  cases  the  propagation  is  partly  caused  by  the  suspension  of  the 
constituents  of  the  discharge  in  the  atmosphere,  and  partly  by  the  air 
expired  from  the  lungs,  from  the  discharge  passing  down  the  lachrymal 
passages  into  the  nose.  Just  the  same,  in  fact,  as  what  occurs  in  common 
nasal  catarrh,  the  contagious  nature  of  which  depends  chiefly  upon  the 
expired  air. 

The  jyfognnsis  which  may  be  given  in  a  case  of  pvirulent  ophthalmia 
^^^ll  depend  upon  the  stage  and  severity  of  the  disease,  and  also  upon 
the  prevailing  character  of  the  epidemic,  should  such  exist.  It  may  be 
favom-able,  if  the  affection  is  of  a  mild  muco-j)urulent  character  and 
is  due  to  spontaneous  causes ;  or,  having  been  produced  by  contagion, 
if  the  inoculating  matter  was  mild  and  chiefly  mucous  in  character. 
Also,  if  the  redness  and  swelling  of  the  eyelids  and  conjunctiva  are  but 
slight ;  if  the  inflammation  is  chiefly  confined  to  the  palpebral  conjunc- 
tiva, or  if  it  extends  to  the  ocular,  the  chemosis  is  serous  and  soft,  not 
plastic  and  hard ;  if  the  discharge  is  thin  and  scant,  the  cornea  un- 
affected, the  character  of  the  epidemic  mild,  without  any  tendency  to 
the  diphtheritic  form  of  conjunctivitis.  We  must,  on  the  other  hand, 
be  extremely  guarded  in  our  prognosis,  or  even  form  an  unfavourable 
one,  if  the  inflammation  is  very  intense,  the  chemosis  hard  and  larda- 
ceous,  and  so  considerable  as  completely  to  surround  the  cornea  and 
overlap  it ;  if  there  is  any  ulceration  of  the  cornea,  especially  if  this  be 
considerable  in  extent,  and  occurring  early  in  the  disease  ;  if  the  inflam- 
mation shows  a  diphtheritic  character. 

Treatment.  If  the  attack  is  severe,  the  patient  should  be  confined  to 
a  darkened  room,  or  even  to  his  bed.  The  room  must,  however,  be  well 
ventilated,  and  plenty  of  fresh  air  be  admitted,  particularly  if  it  is  occu- 
pied by  several  patients.  Those  who  have  the  disease  in  a  severe  form 
should,  if  possible,  be  separated  from  the  milder  cases.  I  need  hardly 
point  out  that  in  barracks,  unions,  schools,  &c.,  the  healthy  inmates 
should  be  strictly  kept  apart  from  those  who  are  suffering  from  ophthal- 
mia. Their  eyes  should,  moreover,  be  examined  every  day,  in  order 
that  the  first  symptoms  of  the  disease  may  be  detected.  The  patients 
and  attendants  should  be  made  aware  of  the  contagious  character 
of  the  disease,  which  contiuues  as  long  as  the  discharge  remains 
opaque  and  mucous.  Especial  care  must  be  taken  that  the  sponges, 
towels,  water,  &c.,  which  are  employed  for  the  patients  are  not 
used  by  others.  To  guard  them  against  the  risk  of  contagion,  the 
medical  attendants  and  nurses  should  wear  the  curved  blue  eye 
protectors,  more    especially   whilst  applying   the    collyria   or    syi-ing- 


30  DISEASES  OF   THE   CONJUNCTIVA. 

ing  out  the  eyes,  as  a  little  of  tlie  matter  may  otherwise  be  easily 
splashed  into  their  eyes.  If,  by  accident,  any  of  the  discharge  should 
have  got  into  a  healthy  eye,  lukewarm  water  should  be  at  once  injected 
under  the  lids  so  as  to  wash  it  away,  and  then  a  drop  of  a  weak  solu- 
tion (2  grains  to  the  ounce  of  water)  of  nitrate  of  silver  or  sulphate  of 
zinc  should  be  applied  to  the  conjunctiva.  If  only  one  eye  is  affected 
wdth  purulent  ophthalmia  the  other  must  be  at  once,  without  loss  of  time, 
hermetically  closed.  The  common  compress  bandage  will  not  suffice  for 
this  purpose,  for  the  discharge  might  soak  through,  especially  during  the 
night,  when  it  may  run  over  the  bridge  of  the  nose  from  the  affected  to 
the  healthy  eye.  The  best  protection  is  the  following  compress  recora- 
mended  by  V  on  Graefe.  A  pad  of  charpie  or  cotton  wool  should  be  applied 
to  the  eyelids  and  covered  by  diacolon  plaster,  which  is  to  be  fixed  down 
by  collodion,  so  as  to  completely  exclude  the  air.  This  compress  should 
be  removed  twice  daily,  and  the  eye  cleansed  and  carefully  examined.  If 
there  is  any  redness  or  swelling  of  the  conjunctiva,  or  any  discharge 
the  pad  should  be  discontinued,  although  in  some  cases  the  continuance 
of  the  firm  pressure  appears  to  cut  short  the  attack.  A  drop  of  a 
weak  solution  of  nitrate  of  silver  or  sulphate  of  zinc  should  be  at 
once  applied.  Ice  compresses  may  also  be  applied  to  the  eyelids,  as 
they,  according  to  Piringer,  will  often  cut  short  the  attack. 

There  is  generally  not  much  constitutional  disturbance,  except  the 
disease  is  severe,  in  which  case,  more  especially  in  gonorrhoeal 
ophthalmia,  it  is  often  accompanied  by  marked  febrile  symptoms.  If 
the  tongue  is  foul  and  loaded,  a  brisk  purgative  should  be  administered, 
and  the  bowels  be  kept  well  opened.  If  the  patient  is  plethoric  and 
feverish,  coohng  salines  must  be  prescribed,  and  the  diet  be  kept  low. 
Formerly  the  depletory  plan  of  treatment  was  carried  to  great  excess,  and 
venesection  employed  to  such  an  extent  that  we  read  of  cases  in  which 
the  patient  was  bled  "  as  long  as  the  blood  could  be  got  from  the  arm  " 
(Wardrop).  N^ow,  however,  this  course  of  treatment  has  fortunately 
almost  completely  exploded,  and  venesection  is  hardly  ever  employed. 
Indeed  we  not  unfrequently  find  that  patients  suffering  from  purulent 
ophthalmia  are  of  a  weakly  and  cachectic  habit,  in  whom  such  a  line 
of  treatment  would  be  most  injudicious  and  injurious.  In  all  such 
cases  tonics,  especially  quinine  and  steel  with  perhaps  some  ammonia, 
should  be  freely  administered,  the  patients  being  at  the  same  time  put 
upon  a  good,  nourishing  andeasily  digestible  diet,  with  meat  once  or  twice 
a-day,  and,  if  necessary,  they  may  even  be  allowed  a  moderate  quantity 
of  stimulants.  In  this  we  must,  however,  be  guided  by  individual  lon- 
siderations.  If  the  patient  is  restless  and  sleepless,  a  narcotic  should  be 
given  at  night,  as  it  is  a  great  relief  if  he  can  obtain  a  good  night's  rest. 

The  greatest  attention  must  be  paid  to  the  local  treatment.  The 
eye  should  be  frequently  cleansed  of  the  discharge.     The  eyelids  being 


PURULENT    OPHTHALMIA.  31 

^^ 
opened,  a  small  stream  of  lukewarm  water  or  milk  and  water  should 

be  allowed  to  play  gently  upon  them  u.ntil  all  the  discharge  is  washed  "> 
away.  Still  better  is  it  to  employ  for  this  purpose  a  small  syringe,  O  O 
the  nozzle  of  which  is  to  be  gently  inserted  between  the  eyelids.  The 
syringe  should  be  very  carefully  and  delicately  handled,  otherwise 
it  will  bruise  and  irritate  the  eye,  or  even  perhaps  rub  against  the 
cornea.  The  nm-se  must  also  be  very  careful  that  no  drop  of  the 
returning  fluid  is  tlirown  into  her  eye.  In  severe  cases,  the  eye  should 
be  thus  cleansed  every  hour  or  two,  in  milder  cases  three  or  four  tiraes 
daily  ■v\dll  suffice.  The  bichloride  of  mercury  lotion  may  also  be  used 
for  cleansing  the  eye,  instead  of  warm  water.  The  crusts  which  form 
upon  the  eyelashes  should  be  well  soaked  with  warm  water  and  then 
gently  rem.oved,  so  as  not  to  excoriate  the  Hds.  A  little  simple  cerate 
shoiild  be  applied  to  the  edges  of  the  latter,  night  and  morning,  to 
prevent  their  sticking,  or  if  they  are  getting  sore  this  should  be 
exchanged  for  the  citrine  ointment.  If  the  temperature  of  the  lids  is 
but  moderately  increased,  it  is  only  necessary  to  employ  cold  compresses 
for  an  hour  or  two  after  the  application  of  caustics,  for  we  thus  assist 
the  astringent  action  of  the  caustic  upon  the  blood  vessels,  and  also 
moderate  the  reaction  produced  by  it.  But  if  the  attack  is  very 
severe,  and  the  eyelids  very  red,  swollen  and  hot,  a  temporary  use  of 
cold  water  will  not  suffice,  and  we  must  have  recourse  to  a  constant 
application  of  ice  compresses.  They  should  be  applied  in  the  follow- 
ing manner :  slightly  moistened  pledgets  of  lint,  of  a  sufficient  size  to 
cover  both  eyelids,  should  be  laid  upon  a  lump  of  ice  until  they  are 
quite  cold,  when  they  are  to  be  applied  to  the  eyelids  and  changed  as 
soon  as  they  get  the  least  warm.  Several  of  such  pledgets  should  be 
kept  lying  upon  the  ice,  so  that  one  is  always  ready  for  use.  If  the 
temperature  of  the  lids  is  very  high,  the  lint  may  require  to  be  changed 
every  three  or  four  minutes.  It  is,  therefore,  absolutely  necessary  to 
have  a  nurse  for  each  patient  or  at  least  for  every  two.  If  great 
attention  cannot  be  paid  to  the  application  of  the  ice  compresses,  it  is 
better  to  abstain  altogether  from  their  use,  as  they  may  otherwise  do 
more  harm  than  good.  We  must  then  rest  satisfied  with  the  use  of 
cold  water  dressing  or  Goulard  lotion.  When  the  eyelids  become  cooler 
and  less  red,  the  patient  begins  to  find  the  extreme  cold  disagreeable, 
and  then  cold  water  dressing  should  be  substituted  for  the  ice  compress, 
or  it  may  even  be  necessary  to  pass  over  to  the  use  of  warm  fomenta- 
tions. A  constant  small  stream  of  cold  water  may  also  be  allowed  to 
play  upon  the  eyelids  by  means  of  a  small  syphon  connected  with  a 
little  reservoir  placed  at  the  bed  head. 

Local  depletion  is  often  of  gi-eat  benefit.  If  there  is  much  ciliary 
neuralgia,  accompanied  by  great  swelling,  heat  and  redness  of  the  eye- 
lids, and  if  these  symptoms  do  not  readily  yield  to  cold  compresses, 


32  DISEASES  OF  THE  CONJUNCTIVA. 

leeches  should  be  at  once  applied.  The  best  place  for  their  applica- 
tion is  on  the  temple,  about  an  inch  from  the  outer  canthus,  for  if 
they  are  put  close  to  the  eyelids,  they  often  produce  great  oedema  of  the 
lids  which  may  even  extend  to  the  cheek.  Their  number  should  vary 
from  four  to  eight,  according  to  the  requirements  of  the  case.  They 
should  be  applied  two  at  a  time,  so  that  the  effect  may  be  prolonged, 
and  free  after-bleeding  is  to  be  encouraged  by  warm  fomentations. 

If  the  eyelids  are  much  swollen,  very  tense,  and  press  greatly 
upon  the  eyeball,  and  especially  if  the  cornea  is  beginning  to  become 
affected,  the  outer  commissure  of  the  lids  should  be  divided.  This 
will  not  only  mitigate  the  injurious  pressure  of  the  lids  upon  the  eye- 
ball and  cornea,  but  it  will  also  give  rise  to  free  bleeding  from  the 
vessels  which  are  divided,  and  thus  greatly  relieve  the  circulation  of 
the  external  portions  of  the  eye.  The  incision  is  to  be  carried  through 
the  skin  and  fibres  of  the  orbicularis,  but  not  through  the  mucous 
membrane,  otherwise  an  ectropion  might  be  produced. 

We  have  now  to  consider  the  most  important  part  of  the  treatment, 
namely,  the  topical  application  of  caustics  and  astringents.  At  the 
commencement  of  the  disease,  whilst  the  discharge  is  still  but  moderate 
in  quantity,  we  must  be  careful  not  to  employ  too  strong  a  caastic, 
more  especially  if  the  eyehds  are  hard  and  the  conjunctiva  and  papillae 
not  much  swollen,  for  fear  that  there  should  be  a  tendency  to  diphthe- 
ritic conjunctivitis,  which  would  be  greatly  aggravated  by  free 
cauterization.  As  soon  as  the  discharge  has  become  copious,  and  the 
symptoms  of  true  purulent  ophthalmia  are  well  pronounced,  astringents 
must  be  employed  more  energetically.  The  choice  of  the  astringent 
and  the  mode  of  its  application  will  depend  upon  circumstances.  If 
we  have  to  treat  the  person  as  an  out- door  hospital  patient,  and  shall 
perhaps  only  see  him  every  second  or  third  day,  it  will  be  necessary  to 
give  him  a  remedy  which  can  be  readily  and  efficiently  applied  by  some 
attendant.  Under  these  circumstances  I  have  found  the  injection  of 
zinc  and  alum,  as  employed  at  the  Royal  London  Ophthalmic  Hospital, 
Moorfields,  by  far  the  best.  Its  strength,  and  the  frequency  of  its  appli- 
cation, must  vary  according  to  the  sevei'ity  of  the  disease.  I  generally 
employ  a  solution  of  2  gr.  of  sulphate  of  zinc  and  4  to  6  gr.  of  alum  to 
*^  the  ounce  of  distilled  water.  This  is  to  be  injected  between  the  eye- 
lids with  a  small  glass  syi'inge  every  15  or  30  minutes  during  the 
^  day,  and  every  two  hours  at  night.  As  the  condition  of  the  eye 
improves,  it  is  to  be  employed  less  frequently.  Every  second  or  thu-d 
day,  the  surgeon  should  apply  a  drop  or  two  of  a  strong  solution  of 
nitrate  of  silver  (gr.  x  to  3j  of  water)  to  the  inside  of  the  hds,  or  it 
should  be  brushed  over  the  conjunctiva  with  a  camel's  hair  brush  ;  the 
patient  in  the  interval  continuing  with  the  injection.  Lukewarm  water 
should  be  injected  every  half  hour  in  order  to  cleanse  away  the  discharge. 


'%J- 


PURULENT   OPHTHALMIA.  33 

Much  benefit  may  also  be  derived  from  a  solution  of  nitrate  of  silver 
(gr.  X  to  5J  of  water  if  the  case  is  severe)  which  should  be  dropped  into 
the  eye  every  five  or  six  hours,  with  a  quill  or  camel's  hair  brush.  But 
it  is  more  difficult  to  apply  these  drops  properly  and  efficiently  than 
the  injection,  and  it  is  therefore  always  better  that  the  surgeon  should, 
if  possible,  do  this  himself.  My  friend,  Mr.  Moss,  has  very  success- 
fully treated,  at  the  Moorfields  Hospital,  out-patients  suffiiring  from 
very  severe  purulent  or  gonorrhoeal  ophthalmia,  in  the  following 
manner,  which  was,  I  believe,  suggested  to  him  by  Professor  Bonders. 
The  lids  being  well  everted,  he  apphes  with  a  camel's  liau*  brush  a  very 
strong  solution  of  nitrate  of  silver  (gr.  xxx — to  xl  to  the  3J)  to  the.  j^  /}  .  ^ 
conjunctiva  once  a-day.  In  the  intervals  the  patient  uses  an  injection 
of  alum  every  half  hour  or  hour.  Quinine  or  steel  is  at  the  same  time 
given  internally. 

But  if  the  patient  is  in  the  hospital,  or  can  be  frequently  seen  by 
the  surgeon,  I  greatly  prefer  to  apply  the  nitrate  of  silver  in  substance. 
It  has  this  great  advantage,  that  we  can  reg-ulate  and  limit  its  efiect, 
and  prevent  its  coming  in  contact  with  the  cornea  and  the  ocular  con- 
junctiva, which  is  quite  impossible  with  the  solution.  Moreover,  the 
latter  is  easily  decomposed  if  the  discharge  is  copious,  and  its  efiect  is 
thus  impaired.  It  is,  however,  absolutely  necessary  that  the  surgeon 
or  a  skihiil  assistant  should  apply  it,  as  it  cannot  be  entrusted  to  a 
nui'se.  We  are  indebted  to  Von  Graefe*  for  the  scientific  explanation 
of  the  action  of  the  nitrate  of  silver  in  purulent  ophthalmia,  and  for 
very  exact  and  comprehensive  directions  as  to  its  use.  During  a  pro- 
longed stay  in  Berlin,  I  saw  it  employed  most  successfully  in  this  way 
by  Von  Graefe  in  many  cases  of  purulent  ophthalmia. 

Pure  nitrate  of  silver  is  too  strong  to  apply  in  substance  to  the  con- 
junctiva, as  its  escharotic  action  is  too  severe.  It  produces  a  thick 
eschar  which  is  thrown  ofi"  with  difficulty,  hence  the  superficial  portion 
of  the  conjunctiva  is  very  liable  to  become  destroyed,  and  deep  cicatrices 
m.ay  be  produced.  Its  strength  should,  therefore,  be  diluted  by  mixing 
it  with  one-half  or  two-thirds  of  nitrate  of  potash. 

The  apphcation  is  to  be  made  in  the  following  manner.  The  eyehds 
having  been  thoroughly  everted,  so  as  to  bring  the  retro-tarsal  fold 
well  into  view,  the  folds  of  the  conjunctiva  of  the  upper  and  lower  lid 
should  be  allowed  to  cover  the  cornea,  and  thus  protect  it  from  the  /iL/>L'-^^-->i 
action  of  the  caustic.  The  crayon  of  mitigated  nitrate  of  silver  should  •  ?  r 
then  be  Hghtly  passed  over  every  part  of  the  surface  of  the  palpebral 
conjunctiva,  especially  in  the  retro-tarsal  region.  A  solution  of  salt 
and  water  should  then  be  freely  applied  with  a  large  camel's  hair  brush, 
in  order  to  neutralize  the  nitrate  of  silver.  The  caseous  shreds  of 
chloride  of  silver  which  are  thus  formed,  should  be  washed  away  with 

*  Von  Graefe  on  Diphtheritic  Conjunctivitis  (A.  f.  O.,  vol.  I.) 

D 


34  DISEASES   OF   THE   CONJUNCTIVA. 

clean  cold  water,  before  the  lids  are  replaced.  We  can  very  easily 
regulate  the  action  of  the  caustic.  When  but  a  shght  effect  is  required, 
the  crayon  should  be  passed  but  once  or  twice  very  lightly  over  the 
conjunctiva.  If  a  stronger  action  is  desired,  it  may  be  used  with  more 
freedom.  The  neutralization  with  the  salt  and  water  should  not  take 
place  immediately  after  the  application  of  the  caustic,  except  where  the 
effect  of  the  latter  is  to  be  but  very  slight.  It  should  not,  however,  be 
postponed  longer  than  from  ten  to  fifteen  seconds. 

The  caustic  should  not,  as  a  rule,  be  applied  to  the  ocular  conjunctiva, 
for  as  this  is  but  secondarily  affected,  its  swelling  and  inflammation 
will  generally  subside  as  the  condition  of  the  palpebral  conjunctiva 
im.proves.  It  may,  however,  be  necessary  to  do  so,  if  the  chemosis  is 
so  considerable  as  to  protrude  between  the  lids,  and  does  not  yield  to 
free  incisions.  But  it  should  only  be  touched  here  and  there,  and  the 
salt  and  water  should  be  immediately  applied. 

If  the  swelling  of  the  conjunctiva  is  very  considerable,  it  should  be 
freely  scarified  with  a  scalpel  or  Desmarres'  scarifier,  directly  after  the 
neutralization  of  the  caustic ;  and  the  bleeding  should  be  encouraged  by 
the  application  of  hot  sponges,  and  by  slightly  kneading  the  lids 
between  the  fingers.  The  incisions  in  the  papillee  should  be  very 
superficial,  otherwise  deep  cicatrices  will  be  left.  The  lids  should  on 
no  account  be  scarified  before  the  application  of  the  nitrate  of  silver, 
for  the  latter  would  act  too  severely  upon  the  incised  conjunctiva.  If 
the  chemosis  is  great,  incisions  radiating  towards  the  cornea  should  be 
made  in  it,  either  with  a  pair  of  scissors  or  a  scalpel :  or  a  small  fold  of 
conjunctiva  may  be  snipped  out  with  scissors  near  the  outer  edge  of 
the  cornea.  Ice  compresses  are  to  be  applied  directly  after  the  cauteri- 
zation, for  they  diminish  the  inflammatory  reaction,  and  assist  in  the 
contraction  of  the  blood  vessels. 

If  we  watch  the  condition  of  the  eye,  we  shall  find  that  it  becomes 
very  hot  and  painful  directly  after  the  cauterization,  and  that  this  is 
accompanied  by  increased  lachrymation  and  a  mucous  discharge.  The 
eschars  which  are  formed  upon  the  palpebral  conjunctiva  are  shed  in  from 
30 — 60  minutes  in  the  form  of  little  yellowish- white,  rolled-up  flakes. 
Those  on  the  ocular  conjunctiva  remain  somewhat  longer.  The  inflam- 
matory symptoms  soon  subside,  the  conjunctiva  becomes  less  turgid,  the 
lachrymation  and  pui-ulent  discharge  diminish,  and  the  stage  of  remis- 
sion  sets  in,  during  which  the  epithelium  is  regenerated.  When  this  has 
taken  place,  the  original  condition,  as  it  existed  before  the  application  of 
the  caustic,  begins  to  reappear.  The  conjunctiva  becomes  more  red  and 
swollen,  the  discharge  increases  in  quantity,  and  the  inflammatory  symp- 
toms in  severity.  It  is  of  consequence  to  endeavoi^r,  by  renewed  cauteriza- 
tion, to  cut  short  this  third  period  at  the  outset,  before  it  has  regained 
its  original  intensity.     We  shall  thus  bo  able,  by  degi-ees,  to  extend 


PURULENT   OPHTHALMIA.  35 

the  duration  of  the  stage  of  remission,  and  to  diminish  the  intensity  of 
the  inflammatory  stage.  Generally,  it  will  snflB.ce  to  apply  the  crayon 
once  in  24  hours  ;  in  very  severe  cases  it  may  be  necessary  to  do  so 
more  frequently,  but  it  should  never  be  applied  until  the  purulent  dis- 
charge has  again  set  in. 

Von  Graefe  has  shown  that  the  cflfect  of  the  nitrate  of  silver  (although 
it  momentarily  increases  the  congestion),  is  to  contract  the  blood 
vessels,  and  to  accelerate  the  circulation,  which  is  retarded  in  purulent 
ophthalmia,  the  conjunctiva  being  at  the  same  time  very  vascular  and 
congested,  and  its  vessels  dilated ;  moreover,  the  serous  infiltration  of 
the  conjunctiva  is  greatly  relieved  by  the  copious  serous  effusion  which 
follows  the  cauterization.  This  is  the  period  of  remission,  during  which 
the  epithelial  layer  of  the  conjunctiva  is  regenerated. 

If  the  cornea  becomes  cloudy,  a  solution  of  atropine  (gr.  ii  to  §j  of 
distilled  water)  is  to  be  dropped  into  the  eye  three  or  four  times  daily. 
Wliere  the  crayon  is  employed,  the  atropine  should  not  be  used  until  the 
period  of  remission  has  set  in.  If  the  nitrate  of  silver  drops  are  used, 
the  atropine  should  be  apphed  dm-ing  the  intervals,  and  about  two 
hours  after  the  former. 

If  there  is  a  deep  nicer  of  the  cornea,  which  threatens  to  perforate 
the  latter,  we  should  at  once  perform  paracentesis  by  pricking  the 
bottom  of  the  ulcer,  and  letting  the  aqneous  humour  flow  oflF  very 
gently.  The  opening  in  the  cornea  will  thus  be  extremely  small;  a  little 
poi-tion  of  iris  will  fall  against  it,  lymph  will  be  eflPused,  and  the  intra- 
ocular pressure  being  now  taken  oflP,  the  ulcer  will  begin  to  heal  at  the 
bottom.  The  re-accumuJation  of  the  aqueous  humour  will  generally 
sufl&ce  to  detach  the  portion  of  iris  from  the  cornea.  If,  however,  a 
small  anterior  synechia  should  persist,  atropine  drops  should  be  applied, 
in  order,  if  possible,  to  tear  it  through.  It  may  be  necessary  to  repeat 
the  paracentesis  several  times,  if  we  see  that  the  bottom  of  the  ulcer  is 
being  bulged  forwards  by  the  aqueous  humom\  By  such  a  timely  para- 
centesis we  often  limit  the  ulcer  to  a  small  extent,  and  finally  little  or 
no  opacity  of  the  cornea  may  remain.  But,  if  we  permit  the  ulcer  to 
perforate  of  its  o^vn  accord,  the  opening  will  be  much  larger,  for  the 
bottom  of  the  ulcer  becomes  attemiated  and  extended  in  size  before  the 
cornea  gives  way.  The  aqueous  humonr  will  then  escape  with  consider- 
able force,  and  carry  the  iris,  or  even,  perhaps,  the  lens  if  the  perforation 
be  large,  into  the  opening  in  the  cornea,  and  thus  a  considerable  anterior 
synechia,  or  prolapse  of  the  iris,  may  occur.  If,  in  the  latter  case,  the 
pi-olapse  does  not  yield  to  the  action  of  atropine,  it  should  be  pricked 
with  a  fine  needle,  and  the  aqueous  humour  distending  it  be  allowed  to 
flow  off",  which  will  cause  the  prolapse  to  collapse.  This  may  be  repeated 
several  times,  until  the  prolapse  shrinks  and  dwindles  away.  If  this 
does  not  occur,  the  prolapse  should  be  snipped  off"  with  a  pair  of  scissors, 

D  2 


36  DISEASES   OF   THE  CONJUNCTIVA. 

after  having  been  pricked.  Should  the  lens  have  fallen  into  the  opening 
and  be  presenting  through,  it  should  be  at  once  removed,  together,  per- 
haps, with  a  little  of  the  vitreous  humour.  An  incision,  should  be  made 
through  the  central  portion  of  the  perforated  cornea,  with  Von  Graefe's 
narrow  cataract  knife.  If  a  piece  of  iris  protrudes,  this  should  be 
somewhat  drawn  out  and  snipped  off.  The  capsule  should  be  freely- 
lacerated  with  the  pricker,  and  the  lens  will  then  readily  escape  if  a 
little  pressure  is  made  upon  the  eye.  A  little  vitreous  humour  will 
generally  exude,  and  the  lips  of  the  incision  fall  into  close  apposition. 
A  firm  compress  bandage  should  be  carefully  applied,  so  as  to  keep 
the  eye  immovable,  and  the  vitreous  pressed  back.  Should  the  latter 
show  a  tendency  to  protrude  through  the  incision,  and  thus  interfere 
with  its  firm  cicatrization,  it  should  be  pricked,  and  a  little  be  allowed 
to  escape,  the  bandage  being  then  re-applied.  We  may  thus  be  able  to 
save  a  sufficient  portion  of  clear  cornea  to  permit  of  the  subsequent 
restoration  of  some  useful  degree  of  sight,  by  the  formation  of  an  artifi- 
cial pupil. 

If  the  disease  has  become  chronic,  the  nitrate  of  silver  must  be  less 
frequently  applied,  or  it  should  be  exchanged  for,  or  alternated  with,  the 
use  of  sulphate  of  copper  in  substance.  A  crayon  of  this  should  be 
passed  lightly  over  the  palpebral  conjunctiva,  more  particularly  in  the 
retro-tarsal  region,  once  every  day.  Or,  a  solution  of  sulphate  of  copper 
(gr.  ij  ad  5j)  should  be  dropped  into  the  eye  once  or  twice  daily.  The 
astringent  must  be  occasionally  changed,  as  the  conjunctiva  after  a  time 
becomes  accustomed  to  it,  and  it  loses  its  efiect.  Thus,  we  may  alter- 
nate the  sulphate  of  copper  with  a  collyrium  of  the  sulphate,  acetate,  or 
chloride  of  zinc,  alum,  acetate  of  lead,  or  vinum  opii,  or  the  red  or  white 
precipitate  ointment  may  be  applied  to  the  conjunctiva.  If  the  papillae 
are  much  swollen  and  very  prominent,  like  cauliflower  excrescences,  it 
may  be  necessary  to  snip  them  off  with  a  pair  of  scissors. 


4.— GONORRHCEAL  OPHTHALMIA. 

Gonorrhoeal  ophthalmia  is  one  of  the  most  dangerous  and  virulent 
diseases  of  the  eye.  In  the  majority  of  cases  it  presents  the  symptoms 
of  a  very  severe  purulent  ophthalmia,  accompanied  sometimes  by  marked 
constitutional  disturbance. 

Shortly  after  the  infection,  the  patient  experiences  a  feeling  of  tin- 
gling and  smarting  in  the  eye,  as  if  a  little  grit  or  sand  had  become 
lodged  beneath  the  lids.  The  eye  becomes  red,  watery,  and  irritable, 
and  the  edges  of  the  eyelids  somewhat  glued  together  by  a  slight 
greyish  white  discharge.  These  symptoms  rapidly  increase  in  severity, 
and  the  disease  quickly  assumes  the  character  of  purulent  ophthalmia  of 


GONORRHCEAL   OPHTHALMIA.  37 

an  aggravated  form.  The  eyelids  become  greatly  swollen,  hot,  red,  and 
cedematous,  the  conjunctiva  very  vascular,  swollen,  and  villous  ;  the 
chemosis  is  often  also  very  considerable,  enveloping  and  overlapping  the 
cornea,  and  protruding  between  the  lids;  The  discharge  is  thick  and 
creamy,  and  perhaps  so  profuse  that  it  oozes  out  between  the  lids,  and 
when  they  are  opened  streams  over  the  cheek.  There  is  always  great 
danger  of  the  cornea  becoming  affected  with  deep  and  extensive  ulcera- 
tion, which  frequently  quickly  leads  to  perforation.  The  constitutional 
symptoms  are  often  severe ;  the  patients  being  generally  in  a  feeble 
and  weakly  condition,  their  general  health  having  perhaps  suffered  from 
the  existence  of  the  gonorrhoea. 

Sometimes  the  disease  shows  from  the  outset  a  marked  tendency  to 
assume  the  character  of  diphtheritic  conjunctivitis,  and  this  proves 
especially  dangerous  to  the  eye.  In  snch  cases,  we  notice  that  the  con- 
junctiva, instead  of  presenting  the  usual  red,  vascular,  succulent 
appearance  common  to  purulent  ophthalmia,  becomes  pale,  smooth,  and 
infiltrated  with  a  fibrinous  exudation.  The  discharge  is  also  quite 
different,  being  thin,  grey,  and  watery.  The  cases  of  gonorrhcBal 
ophthalmia  which  prove  so  virulent  as  to  destroy  the  cornea  in  the  course 
of  a  few  hours  are  mostly  of  this  diphtheritic,  or,  at  all  events,  of  a 
mixed  character.  In  England,  however,  this  form  is  very  rare,  and 
amongst  the  numerous  cases  of  gonorrhoeal  ophthalmia  which  have  come 
under  my  care  or  observation,  I  have  only  met  with  the  purulent 
disease. 

Gonorrhoeal  ophthalmia  is  always  due  to  contagion,  and  the  doctrine 
of  metastasis  (which  was  formerly  much  in  vogue)  is  quite  untenable. 
It  may'"be'praduced  during  any  stage  of  the  urethral  disease,  but  about 
the  third  week  of  the  existence  of  the  latter  is  the  most  dangerous 
period,  the  discharge  being  then  very  copious,  thick,  and  noxious.  I 
have,  however,  seen  the  discharge  from  a  gleet  give  rise  to  severe  and 
even  destructive  gonorrhoeal  ophthalmia.  Medical  men  unfortunately 
sometimes  altogether  neglect  to  warn  their  patients  of  the  danger 
of  contagion  from  the  ui^ethral  discharge.  I  have  met  with  several 
instances  of  severe  and  destructive  gonorrhoeal  ophthalmia,  in  which 
the  patients  had  never  been  informed  by  their  medical  men  of  the  very 
contagious  character  of  the  discharge. 

Gonorrhoeal  ophthalmia  is  far  more  frequent  amongst  men  than 
women,  and  the  right  eye  is  the  one  usually  attacked,  the  corresponding 
hand  being  most  used  for  the  purpose  of  ablution,  etc.,  and,  _  conse- 
quently, most  prone  to  be  the  carrier  of  the  virus  to  the  eye. 

If  we  see  the  patient  very  shortly  after  the  inoculation,  the  eye 
should  be  thoroughly  syringed  out  with  lukewarm  water,  and  a  drop  or 
two  of  a  weak  solution  of  nitrate  of  silver  (gr.  ij.  ad  5j)  be  at.  once 
appUed,  and  repeated  at  the  intervals  of  a  few  hours.     Ice  compresses 


38  DISEASES  OF   THE   CONJUNCTIVA. 

may  also  be  employed.  The  other  eye  should  be  at  once  protected  by  an 
hermetical  bandage  against  the  danger  of  contagion.  The  treatment 
must  be  the  same  as  that  for  purulent  ophthalmia,  the  patient's  health 
being  sustamed  by  tonics  and  a  generous  diet.  But  if  the  disease  shows 
a  tendency  to  assume  the  diphtheritic  character,  the  use  of  astringents 
(more  especially  the  nitrate  of  silver)  must  be  particularly  avoided,  and 
the  case  must  be  treated  upon  the  same  principles  as  diphtheritic  con- 
junctivitis, viz.,  by  ice  compresses,  leeches,  and,  perhaps,  the  use  of 
mercurials. 


5.— OPHTHALMIA  NEONATORUM. 

Strictly  speaking,  we  cannot  recognise  this  as  a  special  form,  for  it 
assumes  the  character  either  of  purulent  or  catarrhal  ophthalmia.  It 
demands,  however,  some  special  remarks  as  to  the  treatment  to  be  pur- 
sued. The  inflammation  generally  appears  first  in  one  eye,  the  other 
becoming  affected  a  few  days  later  if  preventive  measures  are  not  at 
once  taken.  The  symptoms  of  the  disease  vary  from  those  of  mild 
catarrhal  conjunctivitis,  to  those  of  severe  pui'ulent  ophthalmia.  On 
account  of  the  laxity  of  the  tissues,  there  is  great  serous  infiltration 
and  swelling  of  the  eyehds,  even  perhaps  in  the  milder  cases.  The 
papilla  of  the  conjunctiva  also  become  very  prominent  and  swollen ; 
and  there  is  often  a  great  tendency  to  ectropion. 

It  has  been  stated  by  some  authorities  that  the  cornea  is  more  fre- 
quently implicated  in  infants  than  in  adults,  but  this  does  not  appear 
to  be  the  case,  although  suppuration  of  the  cornea  is  of  but  too  fi-equent 
occurrence,  frora  the  feeble  and  weakly  condition  of  many  of  the  infants, 
and  the  negligence  and  want  of  care  in  the  nursing,  which  is  so  often 
met  with  amongst  the  out-patients  of  an  hospital. 

Contagion  is  a  very  frequent  cause  of  the  disease.  The  infection 
often  occurs  from  some  leucori'hoeal,  or  perhaps  gonorrhceal  discharge 
during  the  passage  of  the  child  through  the  vagina.  But  it  must  be 
always  remembered  that  other  vaginal  discharges  besides  the  gonorrhceal 
may  induce  this  ophthalmia.  The  disease  may  also  be  produced  by  the 
child's  eyes  being  vriped  and  cleansed  with  a  sponge  or  cloth  which  is 
soiled  with  some  vaginal  discharge.  Frequently  the  ophthalmia  is  not 
due  to  contagion  at  all,  but  is  caused  by  the  sudden  exposure  of  the 
infant  to  the  irritation  of  bright  dazzling  light,  cold  winds,  or  by  a  want 
of  cleanliness  in  washing  the  eyes.  This  is  proved  by  the  fact  that  the 
disease  sometimes  does  not  make  its  appearance  till  some  weeks  after 
birth  ;  whereas,  if  it  were  due  to  contagion  this  would  not  be  the  case, 
for  we  find  in  inoculation  that  the  period  of  incubation  lasts  from  12  to 
70  hours. 


OPHTHALMIA  NEONATORUM.  39 

The  course  of  oplithalmia  neonatorum  is  generally  much  less  intense 
than  that  of  purulent  ophthalmia  (clue  to  contagion)  in  adults. 

Although  the  pure  diphtheritic  conjunctivitis  never  occurs  in  new- 
bom  infants,  yet  we  sometimes  meet  with  mixed  forms,  in  which  during 
the  early  stages,  the  purulent  ophthalmia  shows  a  more  or  less  marked 
tendency  to  assume  a  somewhat  diphtheritic  appearance.  The  lids  are 
not  soft  and  flaccid  (doughy),  but  stiflf,  and  rather  hard,  and  their  tem- 
perature is  high.  The  surface  of  the  conjunctiva  is  of  a  pale  or 
yellowish  grey  tint,  the  papillge  being  not  much  swollen ;  the  discharge, 
instead  of  being  thick  and  creamy,  is  thin,  fibrinous,  and  rather  flaky, 
so  that  it  adheres  somewhat  to  the  conjunctiva,  and  has  to  be  removed 
with  forceps,  exposing  beneath  it  a  red  succulent  surface.  These  pecu- 
liar symptoms  are  simply  due  to  a  stasis  in  the  blood-vessels,  and  the 
fibrinous  mass  does  not  penetrate  into  the  substance  of  the  conJTinctiva, 
as  is  the  case  in  the  diphtheritic  form. 

The  prognosis  will  depend  upon  the  severity  of  the  attack,  the  con- 
dition of  the  cornea,  and  if  there  be  any  epidemic,  upon  the  nature  of 
this  in  general. 

Treatment. — The  first  indication  is  prevention.  The  eyes  should  be 
washed  with  warm  water  directly  after  birth,  and  this  should  be  re- 
peated frequently.  The  sponges,  towels,  lint,  etc.,  should  be  perfectly 
clean,  and  used  for  no  other  purpose.  The  hands  of  the  nurse  and  the 
mother  (more  especially  if  she  is  suffering  from  any  vaginal  discharge), 
should  always  be  washed  before  the  infant's  eyes  are  cleansed.  If  the 
disease  breaks  out  in  a  workhouse,  or  lyiaig-in- charity,  the  children 
suffering  from  it  should  be  separated  from  the  healthy,  and  should  have 
special  nurses.  Moreover,  they  should  not  be  crowded  together  into 
small  ill- ventilated  wards,  but  enjoy  plenty  of  fresh  air. 

If  the  eyes  look  red  and  irritable,  with  a  discharge  at  the  corners  or 
upon  the  lashes,  a  weak  collyinum  of  sulphate  of  zinc  (gr.  j — ji  ad  3j) 
shonld  be  used  2 — 3  times  daily,  and  the  eyes  frequently  cleansed.  But 
if  the  discharge  is  thick,  creamy,  and  considerable  in  quantity,  stronger 
astringents  must  be  employed.  In  out-patient  practice,  where  the 
patients  can  only  be  seen  two  or  three  times  a  week,  by  far  the  best 
remedy  is  the  injection  of  the  collyrium  of  alum  and  zinc  (Zinc. 
Sulph.  gr.  ij.,  Alum.  gr.  iv.,  Aq.  dist.  Sj.).  A  little  of  this  is  to  be 
injected  with  a  glass  syringe  between  the  lids  every  quarter  or  half- 
hour  dui'ing  the  day,  and  every  three  or  four  hours  during  the  night. 
The  frequency  of  the  injection  must  be  regulated  according  to  the 
severity  of  the  disease.  The  eyes  are  to  be  cleansed  before  the  use  of 
the  collyrium  by  the  injection  of  luke-warm  water  between  the  lids,  so 
that  the  discharge  may  be  washed  away.  If  the  patient  can  be  seen 
every  day,  or  even  more  frequently,  the  mitigated  nitrate  of  silver,  in 
substance,  should  be  used,  as  we  can  regulate  and  localise  its  effect  far 


40  DISEASES   OF   THE   CONJUNCTIVA. 

better  than  can  be  done  if  injections  or  colljria  are  employed.  The 
edges  of  the  lids  shonld  be  smeared  night  and  morning  with  a  little 
simple  cerate,  or,  if  they  are  sore  and  excoriated,  with  a  little 
citrine  ointment.  Por  severe  cases,  other  local  remedies  are  also  indi- 
cated, e.g.,  leeches,  scarification,  cold  compresses,  etc.  But  we  unfor- 
tunately encounter  great  difficulty  in  their  proper  employment,  except 
in  a  special  hospital,  or  iu  private  practice.  The  nui'ses  or  parents  are 
often  so  careless  in  the  application  of  cold  compresses  that  they  do  more 
harm  than  good. 

If  there  is  a  tendency  to  stasis  in  the  circulation  of  the  conjunctiva, 
and  to  the  formation  of  the  above-named  fibrinous  membranes,  the 
astringents  must  be  used  with  care,  and  their  efiect  closely  watched. 
If  mitigated  nitrate  of  silver  in  substance  is  employed,  it  should  be  only 
lightly  used,  at  once  neutralized  by  salt  and  water,  and  the  cauterization 
be  followed  by  free  scarification  and  the  application  of  cold  compresses 
to  the  eyelids.  Wecker,  moreover,  recommends  the  administration  of 
small  doses  of  calomel  during  this  condition  of  cyanosis  of  the  con- 
junctiva. Afiections  of  the  cornea  must  be  treated  in  the  same  way  as 
in  purulent  ophthalmia.  The  health  of  the  mother  or  wet-nurse  should 
also  be  attended  to.  If  the  infant  is  feeble,  and  the  ophthalmia  shows  a 
tendency  to  become  chronic,  and  the  mother  is  out  of  health,  tonics  and 
a  generous  diet  should  be  prescribed. 

6.— DIPHTHERITIC  CON"JIIN"CTiyiTIS. 

This  extremely  dangerous  disease  is  fortunately  very  rare  in  England. 
I  have  never  yet  met  with  a  case  of  pure  diphtheritic  conjunctivitis 
here,  whereas  during  my  residence  in  Berlin,  I  had  the  opportunity  of 
seeing  many  cases  in  Von  Graefe's  clinique.  Indeed,  it  is  of  frequent 
occurrence  in  that  city,  and  often  assumes  a  very  severe  and  even 
epidemic  character. 

The  first  symptom  is  very  rapid  and  great  swelling  of  the  eyelids, 
which  are  also  hard  and  firm,  very  hot,  and  exquisitely  tender,  so  that 
the  patient  shrinks  back  and  trembles  at  the  mere  idea  of  their  being 
touched.  The  swelling  and  stiffness  of  the  eyelids  soon  become  so 
great,  that  they  can  hardly  be  opened,  and  certainly  not  everted ; 
whereas  in  purulent  ophthalmia  we  have  seen  that  although  the  eyelids 
may  be  greatly  swollen,  they  are  soft,  flaccid,  and  not  painful  to  the 
touch,  nor  is  the  temperature  very  high ;  they  can  also  be  readily 
everted. 

The  conjunctiva  is  at  first  somewhat  red,  but  soon  assumes  a  gi^eyish 
yellow  tint,  especially  at  the  rctro-tarsal  fold.  It  is  not  soft,  red,  suc- 
culent, and  villous,  as  in  purulent  ophthalmia,  but  thick,  smooth,  and 


DIPHTHERITIC   CONJUNCTIVITIS.  41 

somewhat  glistening.  This  pale,  greyish-yellow  tint  is  chiefly  due  to 
the  firm,  gelatino-fibrinous  infiltration  of  the  substance  of  the  con- 
junctiva, which  compresses  the  blood-vessels,  and  gives  rise  to  a  great 
retardation,  or  even  stoppage  in  the  circulation.  Numerous  extravasa- 
tions of  blood  may  also  be  noticed  on  the  conjunctiva.  The  chemosis 
is  pale  and  yellow,  but  the  infiltration  is  not  serous  and  transparent, 
but  firm  and  fibi-inous,  pressing  upon  and  strangulating  the  blood-vessels 
which  supply  the  cornea,  and  hence  the  great  danger  which  the  latter 
runs  in  this  disease.  When  the  lids  are  opened,  a  stream  of  hot,  scald- 
ing tears  gush  forth,  mixed  perhaps  with  a  few  yellow  fibrinous  flakes, 
quite  different  to  the  thick  creamy  discharge  in  purulent  ophthalmia. 

Even  deep  scarification  of  the  conjunctiva  fails  to  produce  a  copious 
sanguineous  discharge,  for  the  latter  is  either  thin,  scant,  and  of  a 
reddish-yellow  tint,  or  the  incisions  remain  almost  dry. 

The  discharge  on  the  surface  of  the  conjunctiva  often  assumes  the 
form  of  thin  yellowish,  reticulated  patches,  of  varying  size.  In  some 
cases,  thick  opaque  membranes  are  formed,  which  are  so  coherent  that 
they  can  be  stripped  off"  in  large  pieces,  forming  casts  of  the  lids  and 
the  surface  of  the  eyeball.  Their  forcible  removal  may  cause  consider- 
able bleeding,  but  we  do  not  find,  as  is  the  case  in  purulent  ophthalmia, 
that  the  denuded  conjunctiva  presents  a  red,  succulent,  villous  surface, 
but  we  come  down  upon  another  layer  of  yellowish-grey  fibrinous  infil- 
tration. In  fact,  the  latter  is  not  confined  to  the  surface  of  the 
conjunctiva,  but  extends  more  or  less  deeply  into  its  stroma. 

The  disease  is  not  always  accompanied  by  such  severe  inflammatory 
symptoms,  but  may  run  a  milder  and  less  dangerous  course.  It  may 
occur  as  a  primary  affection,  or  ensue  secondarily  upon  purulent 
ophthalmia,  the  latter  assuming  a  diphtheritic  character. 

In  the  primary  form,  it  generally  sets  in  with  considerable  violence, 
all  the  characteristic  symptoms  showing  themselves  in  two  or  three 
days ;  indeed,  the  disease  may  even  attain  its  acme  in  that  time,  remain 
stationary  for  a  few  days,  and  then  gradually  pass  over  into  the  second 
or  blenorrhoic  stage.  The  latter  is  ushered  in  by  the  following  symp- 
toms : — The  lids  diminish  in  hardness  and  become  more  soft  and  flaccid, 
so  that  they  can  be  everted  with  greater  ease,  and  without  much  pain. 
The  surface  of  the  conjunctiva  assumes  a  more  vascular  and  succulent 
appearance ;  here  and  there  patches  of  fibrinous  exudation  soften  and 
become  detached  from  the  sui-face  of  the  conjunctiva,  which  bleeds 
more  or  less  freely.  The  deep-seated  infiltration  gradually  diminishes, 
and  this  is  accompanied  by  a  corresponding  diminution  in  the  firmness 
and  hardness  of  the  conjunctiva,  which  assumes  a  more  vascular,  suc- 
culent, and  villous  appearance,  the  discharge  at  the  same  time  becoming 
thick,  creamy,  and  copious.  In  fact,  the  disease  now  presents  the 
characters  of  purulent  ophthalmia,  with  this  peculiarity,  however,  that 


42  DISEASES   OF   THE  CONJUNCTIVA. 

there  is  a  great  tendency  to  tlie  formation  of  cicatrices,  and  shrinking 
of  the  conjunctiva.  But  sometimes  there  is  a  relapse  after  the  purulent 
stage  has  set  in,  the  diphtheritic  symptoms  reappearing  with  more  or 
less  prominence,  and  such  relapses  may  occur  more  than  once.  This  is 
especially  the  case  if  the  use  of  astringents  has  been  commenced  too 
early,  or  they  have  been  too  energetically  employed. 

Diphtheritic  conjunctivitis  is  a  far  more  dangerous  disease  than  puru- 
lent ophthalmia,  on  account  of  the  frequency  and  severity  of  corneal 
complications.  Extensive  ulceration  or  suppuration  of  the  cornea  is  but 
too  frequent.  The  dense,  hard,  infiltrated  conjunctiva  presses  upon  the 
cornea  and  upon  the  blood-vessels  which  supply  it,  hence  the  nutrition 
of  the  cornea  is  greatly  impaired,  and  its  suppuration  may  rapidly  ensue. 
If  the  cornea  is  about  to  be  implicated,  we  notice  that  its  lustre  is 
slightly  diminished,  its  surface  faintly  clouded,  and  its  epithelial  layer 
somewhat  abraded.  A  yellow  infiltration  appears,  which  rapidly  passes 
over  into  an  ulcer,  the  latter  extends  quickly  in  circumference  and 
depth,  until  a  very  considerable  portion  of  the  cornea  may  be  involved. 
In  some  cases,  when  the  ulcer  has  extended  nearly  as  far  as  the  mem- 
brane of  Descemet,  the  floor  of  the  ulcer  becomes  somewhat  raore 
transparent  and  bulged  forward  by  the  aqueous  humour.  The  patient's 
sight  is  temporarily  much  improved,  and  he  is  buoyed  up  by  the  vain 
hope  that  his  eye  is  safe  ;  but  perforation  generally  rapidly  ensues.  If 
the  disease  is  very  severe,  and  the  cornea  has  become  afiected  at  a  very 
early  stage,  the  whole  cornea  may  suppurate,  give  way,  and  a  consider- 
able amount  of  the  contents  of  the  globe  escape.  The  perforation  is 
soon  blocked  up  by  a  glutinous  exudation,  which  also  glues  down  the 
edges  of  the  prolapsed  portion  of  iris  to  the  cornea.  The  earlier  the 
cornea  becomes  afiected,  the  greater  is  the  danger,  for  the  ulcers  which 
occur  at  a  later  period  of  the  disease  spread  less  rapidly,  and  show  a 
greater  tendency  to  limitation.  We  also  find,  as  in  purulent  ophthalmia, 
that  those  eyes  are  safest  in  which  there  exist  either  vascular  ulcers  of 
the  cornea,  or  a  vascular  pannus,  for  then  the  nutrition  of  the  cornea  is 
carried  on  by  the  blood-vessels  upon  its  surface,  and  there  is  far  less 
danger  of  its  undergoing  suppuration. 

The  prognosis  is  very  unfavourable  if  the  disease  is  at  all  intense, 
and  the  character  of  the  epidemic  (if  such  exist)  is  severe,  and  if  the 
patient  is  an  adult.  It  is  somewhat  more  favourable  in  children,  and 
towards  the  end  of  the  epidemic  ;  also  if  the  first  stage  of  the  disease 
is  not  very  sevci'e. 

In  framing  our  prognosis,  we  must  be  chiefly  giiided  by  the  severity 
of  the  inflammatory  symptoms,  the  amount  of  the  fibrinous  exudation, 
the  swelling  and  hardness  of  the  lids  and  of  the  chemosis,  and  especially 
by  the  condition  of  the  cornea.  If  the  latter  becomes  afiected  very 
shortly  after  (within  24 — 3G  hours)  of  the  outbreak  of  the  disease,  or 


DIPHTHERITIC   CONJUNCTIVITIS.  43 

during  the  first  period,  before  that  of  vascularization  has  set  in,  we 
must  look  upon  the  eye  as  all  but  lost.  If  the  cornea  is  not  implicated 
until  the  second  period  (that  of  purulent  ophthalmia)  has  set  in,  the 
prog^aosis  is  more  favourable,  but  even  in  this  case  we  must  re- 
member that  a  relapse  may  occur,  and  the  safety  of  the  eye  be  again 
endangered. 

The  causes  of  diphtheritic  conjunctivitis  are  very  much  the  same 
as  those  which  may  produce  other  inflammations  of  the  conjunctiva ; 
but  it  must  be  conceded  that  there  is  generally  some  constitutional 
peculiarity  which  determines  the  character  of  the  disease,  the  same 
causes — cxposui'e  to  cold,  di*aughts,  inoculation,  etc. — producing  in 
one  case  a  purulent  or  granular,  in  the  other  a  diphtheritic  ophthalmia, 
moreover  it  generally  affects  both  eyes,  however  much  we  may  guard 
the  second.  It  occtu's  most  frequently  in  weakly  and  scrofulous  persons, 
more  especially  in  children  between  the  ages  of  two  and  eight,  of  a 
delicate,  feeble  habit,  or  affected  with  hereditary  syphilis.  In  them 
it  often  occurs  in  conjunction  with  croup  or  diphtheria.  Contagion  is 
also  a  very  frequent  cause,  for  the  discharge  from  diphtheritic  conjunc- 
tivitis is  exceedingly  contagious.  If  it  be  applied  to  a  healthy 
conjunctiva  it  generally  reproduces  diphtheritic  conjunctivitis,  but  this 
does  not  necessarily  follow.  Sometimes  it  occui^s  epidemically,  which 
is  especially  the  case  in  some  parts  of  Germany,  more  particularly  in 
Berlin. 

The  injudicious  and  excessive  use  of  caustics  in  the  treatment  of 
purulent  ophthalmia  (more  particularly  that  of  children)  may  change  the 
disease  into  the  diphtheritic  form. 

With,  regard  to  the  treatment,  it  must  be  confessed  that  we  have, 
unfortimately,  but  little  control  over  the  disease  during  the  first 
period. 

Our  first  care  must  be  to  remove  the  patient  from  all  noxious 
influences  that  may  keep  up  and  intensify  the  disease,  and  every  effort 
must  be  made  to  prevent  its  spreading. 

We  must  endeavour  to  diminish  the  inflammatory  symptoms,  more 
particularly  if  they  assume  a  sthenic  type.  If  the  eyelids  are  greatly 
swollen,  and  very  red,  hot,  stiff,  and  painful,  ice  compresses  must  be 
employed  almost  without  intermission,  being  changed  as  soon  as  they 
become  at  all  warm.  They  must  be  less  frequently  employed  when  the 
second  period  (that  of  vascularization)  is  setting  in,  and  when  this  has 
become  fully  estabKshed  they  muvst  be  only  used  after  the  cauterization. 
The  effect  of  the  cold  is  to  counteract  the  stasis,  by  causing  contraction 
of  the  vessels,  and  it  also  acts  as  a  sedative,  giving  great  relief  to  the 
intense  pain.  But  if  there  is  extensive  ulceration  of  the  cornea,  the  cold 
compresses  should  be  replaced  by  warm  fomentations,  so  that  we  may 
produce  an  acceleration  in  the  vascularity  of  the  conjunctiva.     Indeed, 


44  DISEASES   OP   THE   CONJUNCTIVA. 

lately  some  surgeons,  especially  Berlin*  and  Mooren,t  liave  recommended 
the  substitution  of  warm  fomentations  for  tlie  ice  compresses,  on  the 
ground  that  they  bring  about  the  second  period  more  rapidly.  Thus 
they  may  prove  of  advantage  when  ulceration  of  the  cornea  occurs 
during  the  first  period,  and  the  ulcer  shows  no  tendency  to  become 
limited  or  vascularized,  for  the  tendency  to  necrosis  is  markedly  aggra- 
vated by  the  application  of  cold  or  of  caustics.  Mooren  formerly  always 
employed  ice  compresses,  but  in  later  years  he  has  substituted  the  use 
of  warm  poultices,  together  with  derivatives  internally.  But,  then  he 
himself  admits  that  the  disease  never  appears  in  Diisseldorf  with  the 
extreme  intensity  that  it  so  often  assumes  in  Berlin. 

Local  depletion  also  proves  of  much  service.  Unfortunately,  the 
disease  occurs  so  frequently  in  anemic  and  cachectic  individuals,  that 
we  generally  cannot  make  a  full  use  of  this.  In  adults,  more  particularly 
if  the  disease  is  due  to  contagion,  and  the  patient  robust  and  strong, 
leeches  should  be  applied  in  large  quantities  to  the  temples,  or  at  the 
upper  angle  of  the  nose.  Tlu"ee  or  four  leeches  should  be  appHed 
at  a  time,  and  as  soon  as  these  drop  off  they  are  to  be  replaced  by 
others.  But  care  must  be  taken  not  to  push  this  remedy  too  far, 
especially  in  feeble  persons,  for  by  greatly  weakening  the  patient  we 
increase  the  danger  of  sloughing  of  the  cornea.  In  very  severe  cases 
as  many  as  30 — 40  leeches  (Wecker)  or  even  a  greater  quantity 
(Graefe)  may  have  to  be  applied  before  any  impression  is  made  upon 
the  disease. 

Scarification  is  but  of  little,  if  any,  use  during  the  first  stage,  for 
only  a  very  small  quantity  of  blood  is  obtained ;  indeed,  sometimes  it 
may  even  do  positive  harm,  being  followed  by  a  more  considerable 
fibrinous  infiltration  ;  but  when  the  second  stage  has  set  in,  when  the 
conjunctiva  has  become  more  vascular  and  there  is  an  efiusion  of  serum 
into  it,  scarification  is  often  of  much  benefit.  The  incisions  should  be 
somewhat  deeper  than  in  purulent  ophthalmia,  and  the  bleeding  be 
kept  up  by  kneading  the  hds. 

In  order  to  hasten  the  vascularization  and  the  breaking  down  and 
elimination  of  the  fibrinous  infiltration  of  the  conjunctiva,  the  system 
should  be  got  as  quickly  as  possible  under  the  influence  of  mercury,  so 
that  salivation  may  be  produced  in  the  course  of  30 — 40  hours.  The 
mercury  may  either  be  administered  internally  in  the  form  of  calomel 
and  opium  (calomel  gr.  ss. — gr.  j  every  2 — 3  hours)  in  doses  varying 
with  the  age  of  the  patient,  or  from  5ss — 5j  ^^  ^^^  mtercurial  ointm.ent 
should  be  rubbed  in  three  times  daily.  In  very  severe  cases  the 
rapidity  with  which  the  fibrinous  infiltration  pervades  the  conjunctiva 
is  often  so  great  that  the  cornea  becomes  implicated  and  the  eye  lost, 

*  "  Kl.  Monalsbl."     18G4. 

+  "  Ophtlialmiatrisclie  Beobaelitungcn,"  p.  70. 


GRANULAR  OPHTHALMIA.  45 

before  the  system  can  be  brought  under  the  influence  of  mercury. 
Moreover,  the  fi^ee  use  of  this  remedy  is  often  contra-indicated  by  the 
very  feeble  and  cachectic  condition  of  the  patient. 

\VTien  the  disease  is  passing  over  into  the  second  stage,  and  is 
assuming  more  and  more  the  character  of  purulent  ophthalmia,  we 
must  gradually  commence  the  use  of  the  mitigated  nitrate  of  silver. 
But  at  first  the  cauterization  must  be  employed  with  great  care  and 
discretion,  as  there  is  always  the  risk  of  causing  a  relapse  if  it  be  used 
with  too  great  a  freedom  at  once.  Should  symptoms  of  stasis  re-appear 
the  cauterization  must  be  immediately  abandoned  until  these  have  dis- 
appeared, and  the  disease  again  assumes  the  purulent  character. 


7.— GRANULAR  OPHTHALMIA. 

It  has  been  ah-eady  mentioned  that  in  catarrhal  and  purulent 
ophthalmia,  the  papillae  of  the  conjunctiva  are  often  much  swollen  and 
hypertrophied,  forming  more  or  less  prominent  elevations  on  the  pal- 
pebral conjunctiva.  They  appear  in  the  form  of  bright  or  bluish  red, 
velvety,  succulent  elevations,  which  have  no  distinct  pedicle,  but  seem 
to  pass  over  into  the  tissue  of  the  conjunctiva.  They  are  ranged  in 
rows,  and  are  of  course  confined  to  that  portion  of  the  conjunctiva 
which  contains  papillae.  Commencing  at  about  a  line  from  the  free 
margin  of  the  hd,  they  extend  slightly  beyond  its  tarsal  border  ;  their 
sides  are  generally  flattened,  on  account  of  the  papillge  being  pressed 
against  each  other.  They  are  often  very  conspicuous  at  the  angles  of 
the  eye,  and  assume  also  a  considerable  size  near  the  retro-tarsal  fold, 
looking  perhaps  like  large  warty  excrescences.  The  name  of  granular 
lids  is  but  too  often  given  to  this  hypertrophied  condition  of  thepapillEe, 
instead  of  being  limited  to  the  true  granulations,  which  are  neo-plastic 
formations  and  not  swollen  papillee.  On  account  of  this  error,  the 
greatest  confusion  still  reigns  upon  this  subject,  a  confusion  which  not 
only  materially  affects  the  diagnosis  but  also  the  treatment  of  the 
disease.  What  has  tended  still  more  to  foster  this  misconception  of 
the  real  nature  of  granular  ophthalmia  is  the  fact,  that  true  granulations 
are  generally  accompanied  in  the  course  of  their  development,  by  a 
more  or  less  swollen  and  hypertrophied  condition  of  the  papillge.  If 
the  latter  gain -a  considerable  prominence  the  granulations  may  even  be 
hidden  by  them.  Stellwag  de  Carion*  apphes  the  term  of  "  pajoillary 
trachoma  or  granulations^'  to  these  hypertrophied  papillae,  and  I  see  no 
objection  to  retaining  this  name,  if  it  be  only  remembered  that  these 
differ  altogether  in  their  natm^e  and  mode  of  development  from  the 
true  granulations. 

*  "  Pracktische  Augenheilkunde,"  3rd  edition,  p.  404.     1867. 


46  DISEASES   OF   THE  CONJUNCTIVA. 

Before  proceeding  to  the  consideration  of  granular  ophthalmia,  I 
ninst  call  especial  attention  to  a  peculiar  vesicular  condition  of  the 
conjunctiva,  which  is  fi*equently  premonitory  of  that  affection.  It  is  a 
matter  of  surprise  that  this  condition,  which  has  been  so  carefully  and 
elaborately  described  by  several  eminent  continental  writers,  more 
especially  Stromeyer,  Bendz,  and  Warlomont,  should  have  apparently 
altogether  escaped  the  attention  of  many  English  ophthalmic  surgeons  ; 
indeed,  we  are  principally  indebted  to  two  distinguished  English 
military  surgeons*  for  giving  this  subject  due  prominence  in  our 
medical  literatui'e,  and  calling  the  attention  of  the  profession,  and  more 
especially  of  army  medical  men,  to  a  condition  of  the  eye  wliich  is 
very  important  to  all  who  have  the  charge  of  large  bodies  of  men,  e.g., 
soldiers,  paupers,  convicts,  etc. 

This  vesicular  condition  of  the  conjunctiva  is  distinguished  by  the 
following  symptoms : — On  everting  the  loAver  eyelid,  we  notice  upon  it 
small,  round,  transparent  bodies  like  little  sago  grains  or  herpetic 
vesicles,  which  are  situated  directly  beneath  the  epithelium.  They 
mostly  make  their  appearance  first  on  the  lower  eyehd,  and  may, 
indeed,  remain  confined  to  it,  but  they  generally  extend  to  the  upper 
eyehd,  and  I  have  seen  a  few  rare  instances  in  which  they  encroached 
,  considerably  upon  the  ocular  conjunctiva.  The  vesicles  are  sometimes 
isolated  and  but  few  in  number,  being  sparsely  scattered  about  the 
conjunctiva  especially  near  the  outer  angle  of  the  eye.  In  other  cases 
they  are  studded  thickly  over  the  palpebral  conjunctiva  and  retro-tarsal 
fold.  They  cannot  be  emptied  of  their  contents  by  pricking,  and  differ 
in  this  from  the  sudamina  of  herpes,  and  the  serous  elevation  of  the 
epithehum  of  the  conjunctiva,  which  is  occasionally  met  with  in 
catarrhal  ophthalmia ;  moreover,  in  the  latter  condition  the  vesicles  are 
much  larger.  The  vesicles  consist  of  a  stroma  of  connective  tissue 
containing  nucleated  cells  like  lymph  corpuscles,  with  a  little  fluid. 
They  are  surrounded  by  a  dehcate  layer  of  condensed  connective  tissue, 
which  has  no  proper  enveloping  membrane,  but  passes  over  into  the 
neighbouring  less  condensed  tissue.  With  a  fine  needle  we  may  often 
succeed  in  removing  them  entire.  They  seem  to  be  identical 
in  structure  with  the  closed  follicles  of  the  intestines,  etc.  Some- 
times these  vesicles  appear  without  any  change  in  the  conjunctiva. 
Generally,  however,  there  is  an  increased  vascularity  of  this  mem- 
brane with  some  swelling,  more  especially  at  the  retro-tarsal  fold.  The 
vessels  of  the   conjvmctiva  are  very  apparent,   and  often  of  a  dusky 

*  I  refer  liere  to  the  excellent  and  very  interesting  articles  on  "  Military  Oph- 
thalmia," by  Dr.  Frank,  late  of  the  Army  Medical  Department,  and  by  Dr.  Marston. 
Both  deserve  tlie  careful  study  of  all  surgeons.  The  first  appeared  in  the  "  Army 
Medical  Blue  Book,"  of  1862;  the  second  in  Beale's  "Archives  of  Medicine," 
No.  xi.     1862. 


GRANULAR  OPHTHALMIA.  47 

bluish-red  colour,  sending  small  brandies  towards  the  vesicles,  which 
may  appear  arranged  in  rows  like  little  transparent  beads.  But  this 
hyper^emic  condition  may  sometimes  mask  the  presence  of  the  vesicles, 
especially  if  they  are  small  and  not  very  numerous,  so  that  they  might 
readily  be  overlooked  by  a  superficial  observer.  If  the  conjunctiva  is 
however  examined  through  a  magnifying  glass,  they  will  be  easily 
distinguished. 

If  the  hyperaemia  of  the  conjunctiva  is  but  slight,  these  .vesicles 
may  exist  for  a  very  long  time,  for  months  or  years,  without  producing 
any  sensible  discomfort  or  symptoms  of  inflammation.  The  patient  may 
either  be  quite  unaware  that  there  is  anything  the  matter  with  his  eyes, 
or  he  may  only  notice  a  slight  sensation  of  pricking  or  itching  in  the 
eye,  the  lashes  being  perhaps  somewhat  glued  together  in  the  morning. 
There  may  also  be  a  tendency  to  irritability  of  the  eyes  during  reading 
or  wi-itiug,  more  especially  by  artificial  light.  Sometimes,  however, 
even  these  symptoms  are  entirely  absent. 

Tliis  vesicular  condition  of  the  conjunctiva  is  due  to  an  enlargement 
of  the  closed  lymphatic  folhcles  of  Krause,  which  are  situated  directly 
beneath  the  epithelium,  and  which  are  not  apparent  in  a  normal  state  of 
the  conjunctiva,  but  become  swollen  and  enlarged  when  this  membrane 
is  in  an  irritable  condition.  Stromeyer*  called  special  attention  to 
these  vesicular  granulations,  but  supposed  that  they  were  pathological 
products  and  did  not  exist  in  a  healthy  conjunctiva.  The  researches  of 
Krause  and  Dr.  Schmidt  of  Berlin  have,  however,  distinctly  proved 
that  they  are  physiological  organs,  which  are  not  apparent  to  the  naked 
eye  Avhilst  the  conjunctiva  is  in  a  normal  condition,  but  are  apt  to 
become  enlarged  into  these  sago  grain  vesicles  from  a  proliferation  of 
theu'  contents,  more  especially  of  their  connective  tissue  elements,  when 
there  is  any  chronic  iri'itation  of  the  conjunctiva. 

Now  it  is  a  very  important  question,  and  one  which  has  not  at 
present  received  a  decided  and  satisfactory  answer,  whether  the  true 
granulations  are  developed  from  these  vesicular  bodies,  or  rather  the 
follicles  of  Krause,  or  whether  they  are  a  distinct  neo-plastic  formation, 
due  to  a  prohferation  of  the  contents  of  the  connective  tissue  cells  of 
the  conjunctiva.  The  former  view  is  maintained  by  several  observers 
of  eminence,  more  especially  Bendz  and  Stromeyer.  But  one  weighty 
argument  against  this  view  is  furnished  by  the  fact  that  true  granula- 
tions sometimes  occur  in  situations  where  these  folhcles  are  more  or  less 
completely  wanting,  as  for  instance  on  the  ocular  conjunctiva.  Wecker 
strongly  advocates  the  view  that  the  true  granulations  are  neo-plastic 
formations,  akin  to  tubercle,  and  are  due  to  a  prohferation  of  the 
contents  of  the  connective  tissue  cells,  and  that  they  consist  of  a  mass 
of  closely  packed  nuclei  with  little  or  no  connective  tissue  between  them. 
*  Stromeyer,  "  Maximen  der  Kriegsheilkunst."     1861. 


48  DISEASES   OF   THE   CONJUNCTIVA. 

At  a  later  stage  the  connective  tissue  becomes  increased  in  quantity,  and 
forms  a  semi-transparent,  gelatinous,  grumous  mass  containing  a  small 
quantity  of  fat.  The  nuclei  diminish  in  number,  and  are  finally  only 
sparsely  scattered  amongst  the  connective  tissue.  It  is  an  important 
fact  that  this  gelatinous  mass  becomes  transformed  at  a  later  stage  into 
a  dense  fibrillar  tissue,  and  that  the  latter  shows  a  great  tendency  to 
contraction,  thus  causing  more  or  less  destruction  of  the  true  conjunc- 
tival tissue.  A  firm  cicatricial  tissue  is  formed,  which  gives  a  streaky 
tendinous  appearance  to  the  inner  surface  of  the  lids ;  the  latter 
gradually  become  shortened,  the  retro-tarsal  fold  almost  obliterated, 
the  tarsal  cartilages  incurved,  thus  giving  rise  to  trichiasis  and 
entropion. 

I  have  never  had  the  opportunity  of  distinctly  tracing  the  trans- 
formation of  the  vesicles  into  true  granulations,  as  they  are  far  less 
frequently  met  with  in  civil  than  in  military  practice.  Moreover,  we 
cannot  watch  the  patients  so  constantly  and  closely.  They  attend 
perhaps  for  some  length  of  time  with  vesicular  granulations,  and  are 
then  lost  sight  of.  The  same  difficulty  exists  with  regard  to  the  deter- 
mination as  to  whether  a  given  case  of  acute  or  clironic  granulations 
has  been  preceded  by  a  vesicular  condition  of  the  lids,  for  it  has  been 
already  stated  that  the  latter  may  exist  for  a  long  time  without  the 
knowledge  of  the  patient.  The  definite  settlement  of  these  questions 
will,  I  think,  depend  very  much  upon  the  observations  made  by  our 
military  confreres,  who  enjoy  every  opportunity  of  constantly  watching 
the  development  of  the  disease  from  its  earHest  (vesicular)  stage  to  the 
latest,  and  their  experience  upon  these  points  is  therefore  of  the  greatest 
importance. 

But  whether  we  accept  or  not  the  theory  that  vesicular  granula- 
tions are  the  first  symptoms  of  granular  ophthalmia,  and  may  become 
developed  into  true  granulations,  there  cannot  be  the  slightest  doubt  that 
they  must  be  regarded  as  a  strongly  predisposing  cause  of  the  latter.  It 
is,  thei-efore,  of  great  importance  that  their  existence  should  be  detected 
as  early  as  possible,  more  especially  where  a  large  number  of  persons  are 
collected  together  as  in  barracks,  workhouses,  and  schools.  For  this 
vesicular  state  of  the  conjunctiva  must  be  watched  with  care  and  anxiety, 
as  it  chiefly  occurs  in  individuals  living  in  a  confined  and  vitiated  atmo- 
sphere, and  under  faulty  sanitary  arrangements.  Proper  hygienic 
measures  should,  therefore,  be  at  once  adopted,  and  the  patients,  if  neces- 
sary, submitted  to  treatment ;  for  if  these  vesicular  granulations  be 
allowed  to  exist  unchecked,  and  such  eyes  are  exposed  to  the  usual 
irritating  influences  met  with  in  marches  and  encampments,  as  for 
instance  exposure  to  wind,  dust,  draughts  of  cold  air  or  bright  glaring 
sunlight,  an  epidemic  of  gTanular  ophthalmia  is  but  too  likely  to  break 
out,  the  ravages  and  extent  of  which  cannot  be  foretold.     It  is  an  inte- 


GRANULAR   OPHTHALMIA.  49 

resting  fact  that  Stromeyer*  also  met  witli  these  vesicular  granulations 
amongst  many  of  the  domestic  animals,  more  especially  pigs,  and  that 
they  existed  in  proportion  to  the  dirty  condition  in  which  these  animals 
were  kept.  These  observations,  moreover,  entirely  agree  with  those 
made  amongst  human  beings,  for  he  found  that  vesicular  granulations 
occur  especially  amongst  persons  inhabiting  crowded,  close,  dirty,  and 
ill- ventilated  dwellings. 

Dr.  Marston,  who  has  enjoyed  great  opportunities  of  studying  the 
phenomena  of  granular  ophthalmia,  holds  similar  views.  He  foundf 
vesicular  granulations  very  prevalent  amongst  the  poorer  classes  in 
Gozo,  especially  where  there  was  a  large  family,  who  live  in  wretchedly 
confined  cabins,  often  with  then'  domestic  animals.  With  regard  to  the 
importance  of  vesicular  granulations,  as  being  indicative  of  a  vitiated 
state  of  the  atmosphere,  he  says,  "  So  certain  do  I  feel  that  the  pre- 
valence of  vesicular  disease  of  the  lids  is  in  direct  ratio  to  the  amount 
and  degree  of  defective  sanitary  arrangements,  that  I  conceive  the  pal- 
pebral conjunctiva  offers  a  delicate  test  and  evidence  as  to  the  hygienic 
conditions  of  a  regiment." 

It  is,  therefore,  of  much  importance  to  discover  the  presence  of 
vesicular  granulations  as  early  as  possible,  in  order  that  the  hygienic 
conditions  of  the  ward  or  sleeping  apartment  of  the  patient  may  be 
thoroughly  examined.  Such  patients  should  be  placed  in  large,  airy, 
well  ventilated  rooms,  which  are  not  exposed  to  the  bright  sunlight. 
Strict  orders  should  also  be  given  that  the  same  sponges,  towels  or 
water  are  not  used  for  others.  Indeed,  it  is  advisable  that  even  healthy 
persons  should  always  wash  in  fresh  water.  It  is  better  to  separate 
those  affected  with  vesicular  granulations  from  the  healthy,  for  I  think 
that  there  can  be  little  doubt  that  vesicular  granulations  are  contagious, 
more  especially  when  they  are  accompanied  by  conjunctival  swelling, 
and  a  little  muco-purulent  discharge.  The  patients  should  be  in  the 
open  air  as  much  as  possible,  care  being  taken,  however,  that  they  are 
not  exposed  to  dust,  wind,  and  bright  sunlight.  Their  diet  should 
be  nutritious  and  easily  digestible.  If  they  are  weak  or  scrofulous, 
quinine,  steel,  cod-liver  oil,  etc.,  should  be  administered.  If  there  is 
slight  conjunctivitis,  with  a  little  discharge,  or  small  yellow  shreds  are 
formed  on  the  conjunctiva,  a  weak  astringent  coUyrium  (Zinc.  Sulph.  or 
Plumb.  Acetat.,  gr.  1—4  ad  5J  Aq.  distill.,  or  Boracis  gr.  iv — vj  ad  ^j) 
should  be  used,  or  the  lids  may  be  very  lightly  touched  with  a  crayon 
of  sulphate  of  copper,  or  still  better,  of  the  lapis  divinus.  Pricking  the 
vesicles  with  a  needle  does  little  or  no  good.  The  eye  douche  or  the 
pulverizer  is  found  to  be  very  beneficial  and  agreeable  to  the  patient. 
I  have  occasionally  met  with  this  vesicular  condition  of  the  eyelids 

*  Stromeyer,  "  Maximen  der  Kriegsheilkunst,"  p.  49.  t  Loc.  cit.,  p.  201. 

E 


50  DISEASES   OF   THE   CONJUNCTIVA. 

amongst  wealthy  persons,  in  whom  the  conjunctiva  was  in  a  state  of 
irritation  from  exposure  to  cold,  bright  hght,  etc.,  and  where  no  faulty- 
hygienic  arrangements  could  be  discovered.  The  affection  readily 
yielded  to  mild  astiingents,  the  eye  douche,  and  careful  guarding  the 
eyes  against  exposure  and  too  much  reading,  etc.  Vesicular  granula- 
tion may  also  be  produced  by  the  long- continued  use  of  atropine.  I 
have  lately  met  with  some  striking  examples  of  this.  The  disuse  of 
the  atropine  and  the  employment  of  a  weak  astringent  collyi-ium,  soon 
caused  the  granulations  to  disappear ;  but,  on  the  re- application  of 
atropine,  a  fresh  crop  rapidly  sprung  up. 

We  mast  now  pass  on  to  the  consideration  of  "  Granular  Ophthal- 
mia." In  practice  we  find  that  we  may  distinguish  two  special  forms 
under  which  the  disease  shows  itself,  viz.,  the  acute,  which  is  often 
accompanied  by  severe  inflammatory  symptoms,  and  the  chronic,  in 
which  these  are  sometimes  but  moderate,  and  occasionally  almost 
entirely  absent.  Of  course  we  meet  with  numerous  cases  which  cannot 
be  properly  placed  in  either  category,  but  show  a  mixed  character. 
Practically,  it  is,  however,  of  much  consequence  to  distinguish  between 
the  acute  and  chronic  forms,  for  great  and  serious  mischief  may  accrue 
from  a  mistaken  diagnosis  and  treatment  of  a  case  of  severe  acute 
granular  ophthalmia. 


ACUTE  GRANULAR  OPHTHALMIA. 

If  the  attack  is  severe,  there  are  generally  marked  inflammatory 
symptoms  ;  the  eyelids  are  red,  swollen,  and  cedematous,  and  on  opening 
the  eye,  we  see  that  there  is  a  good  deal  of  conjunctival  and  subcon- 
junctival injection.  The  degree  of  conjunctival  swelling  varies ;  some- 
times it  is  considerable,  more  especially  in  the  retro-tai'sal  region,  and 
there  may  also  be  marked  serous  chemosis.  The  photophobia  and 
lachrymation  are  often  very  great,  so  that  the  patient  is  qiute  unable  to 
open  the  eye,  and  directly  it  is  attempted,  hot  scalding  tears  flow  over 
the  cheek.  There  is  often  severe  throbbing  pain  in  and  around  the  eye, 
and  perhaps  over  the  corresponding  half  of  the  head.  On  eversion  of 
the  lids,  we  find  that  the  conjunctiva  is  vascular  and  swollen,  and  that 
the  papillae  are  prominent,  red,  and  succulent.  On  closer  inspection 
(with  or  without  a  magnifying  glass)  we  notice,  scattered  between  the 
papillfB,  and  pei'haps  almost  hidden  by  them,  numerous  small,  round, 
white  bodies,  like  sago  gi^ains,  which  are  not,  however,  confined  to  the 
palpebral  conjunctiva,  but  extend  to  the  retro-tarsal  fold.  They  are  also 
sometimes  seen  on  the  ocular  conjunctiva,  and  even  on  the  cornea, 
where  they  give  rise  to  a  superficial  vascular  inflammation  (pannus). 
If  we  examine  the  cornea  in  such  a  case  by  the  oblique  illumination. 


ACUTE   GRAJSULAR   OPHTHiy:.MIA.  51 

and  through  a  magnifying  glass,  we  find  that  this  opacity  is  composed 
of  a  quantity  of  small  elevated  gi'cy  dots,  with  the  epithelium  raised  over 
them.  Numerous  blood  vessels  run  over  from  the  conjunctiva  to  these 
spots,  giving  a  more  or  less  red  tint  to  the  opacity  of  the  cornea.  This 
vascular  opacity  may  involve  a  considerable  portion  of  the  cornea,  and 
is  not  chiefly  confined  to  the  upper  half,  as  is  the  case  in  the  pannus 
produced  by  the  friction  of  granulations  or  inverted  eyelashes  of  the 
upper  lid,  upon  the  surface  of  the  cornea.  Sometimes  small  ulcers 
af)pear  at  the  edge  of  the  cornea.  When  the  acute  stage  has  lasted  for  a 
few  days,  the  symptoms  of  irritation  begin  to  diminish.  The  severe 
pain,  photophobia,  and  lachrymation  decrease,  the  papilla  at  the  same 
time  becoming  more  turgid,  vascular,  and  prominent,  thus  hiding  the 
granulations ;  whilst  the  discharge,  which  has  hitherto  been  chiefly 
watery,  with  perhaps  only  a  few  yellow  flakes  suspended  in  it,  becomes 
thicker  and  muco-purulent  in  character.  The  intensity  of  the  conjunc- 
tival infiammation  varies  greatly ;  sometimes  it  reaches  only  the  catarrhal 
form,  at  others  it  assumes  a  severe  purulent  type.  The  stage  of  puru- 
lent ophthalmia  generally  lasts  for  several  weeks,  and  then  the  symp- 
toms gradually  subside  ;  the  papilla;  diminish  in  size,  and  the  white  sago 
grain  granulations  are  then  perhaps  found  to  have  disappeared,  they  having 
in  fact  been  absorbed  during  the  inflammatory  state  of  the  conjunctiva. 
But  so  favourable  a  result  is  not  always  obtained,  for  on  the  decrease  of 
the  inflammatory  sjTuptoms,  and  the  diminution  in  the  size  of  the  papillje, 
the  white,  and  now  more  prominent,  spots  may  re-appear  between  them, 
the  inflammation  having  been  insufiicient  for  their  absorption.  If  the 
patient  is  exposed  to  any  fresh  exciting  cause,  a  relapse  may  occur,  and 
a  renewed  attack  of  more  or  less  severe  acute  ophthalmia  may  take 
place.     This  is,  however,  far  less  common  than  in  the  chronic  form. 

Contagion  is  a  very  frequent  cause,  for  the  discharge  from  an  eye 
afiected  with  acute  gi'anulations  is  very  contagious,  more  especially 
during  the  muco-purulent  stage.  It  does  not  necessarily  reproduce  the 
same  afiection,  but  like  purulent,  or  even  diphtheritic  ophthalmia,  may 
give  rise  to  catarrhal,  purulent,  or  diphtheritic  conjunctivitis.  This 
will  depend  upon  local  and  individual  circumstances,  and  upon  the  cha- 
racter of  any  epidemic  of  conjuncti\^tis  that  may  be  prevailing  at  the 
time. 

Another  very  fruitful  source  of  acute  granulations  is  defective 
hygiene.     The  long  continued  use  of  atropme  may  also  produce  them. 

The  prognosis  in  acute  granular  ophthalmia  is  generally  favourable, 
if  the  true  nature  of  the  afiection  is  recognised  at  the  outset,  and  a 
proper  course  of  treatment  is  adopted.  But  if  the  disease  is  mistaken 
for  a  case  of  purulent  ophthalmia,  and  freely  treated  by  strong  caustics, 
the  intensity  of  the  irritation  will  be  greatly  increased,  and  the  inflam- 
mation may  even  assume  a  diphtheritic  character.     At  the  best,  the 

E  2 


52  DISEASES  OF   THE   CONJUNCTIVA. 

salutary  iaiflaramation  of  the  conjunctiva  mil  be  suppressed,  and  the 
absorption  of  the  grannlations  checked. 

The  treatment  must  vary  with  the  nature  and  stage  of  the  affection. 
We  must  especially  remember  that  when  the  acute  symptoms  of  irrita- 
tion have  subsided,  our  chief  object  is  to  obtain,  if  possible,  the  absorp- 
tion of  the  granulations  by  keeping  up  a  certain  amount  of  inflamma- 
tion of  the  conjunctiva.  The  degree  of  the  latter  should  just  sufl&ce  to 
promote  this  absorption,  but  should  never  be  allowed  to  become  so  con- 
siderable as  to  arrest  or  retard  it. 

If  there  is  much  photophobia,  lachrymation,  and  ciliary  irritation, 
the  greatest  care  must  be  taken  to  avoid  all  stimulating  applications. 
Atropine  drops  (gr.  ij  ad  3J)  should  be  applied  thi^ee  or  four  times  daily. 
If  they  are,  however,  found  to  keep  up  or  increase  the  irritability, 
they  should  be  at  once  exchanged  for  a  Belladonna  collyrium  (Ext. 
Bellad.  5ss.  ad  Aq.  distill  §j),  which  should  be  applied  somewhat  more 
frequently,  and  in  larger  quantity.  At  the  same  time,  the  compound 
Belladonna  ointment  should  be  rubbed  into  the  forehead  every  four  or 
six  hours,  until  a  slight  papular  eruption  is  produced.  If  the  pain  in 
and  around  the  eye  is  very  severe,  of  a  pulsating,  throbbing  character, 
and  increases  much  towards  night,  a  few  leeches  should  be  applied  to 
the  teruple.  Cold  compresses  are  also  of  much  benefit  in  subduing  the 
irritation  and  relieving  the  pain.  They  must,  however,  be  applied 
vsdth  circumspection,  and  their  effect  watched.  If  the  conjunctiva  is 
much  swollen,  more  especially  in  the  retro-tarsal  region,  it  may  be 
lightly  scarified,  care  being  taken  to  make  the  incisions  very  superficial, 
so  that  no  cicatrices  may  be  left. 

When  the  symptoms  of  irritability  subside,  and  the  disease  assumes 
the  character  of  purulent  ophthalmia,  it  must  be  treated  on  the  same 
principles  as  that  affection.  The  same  rules  as  to  the  choice  and  mode 
of  application  of  caustics  apply,  as  in  the  latter  disease.  The  only 
difference  being,  that  the  cauterization  must  not  be  repeated  so  fre- 
quently, as  we  must  remember  that  it  is  desirable  to  maintain  a  certain 
degree  of  inflammation  in  order  to  favour  the  absorption  of  the  granu- 
lations. But  care  must  be  taken  not  to  commence  the  use  of  caustics 
too  early,  whilst  there  is  still  considerable  irritabihty  of  the  eye,  othei'- 
wise  this  will  be  greatly  increased,  and  infiltrations,  or  even  ulcers  of 
the  cornea,  may  be  produced.  In  those  cases  in  which  we  are  in  doubt 
as  to  whether  the  irritability  of  the  eye  is  not  still  too  great  for  the 
application  of  the  nitrate  of  silver  or  sulphate  of  copper,  it  is  always 
wiser  to  feel  our  way  with  some  milder  application.  For  this  pui"pose 
we  may  try  a  weak  solution  (gr.  vi — x  ad  ^j)  of  the  acetate  of  lead, 
a  little  of  which  should  be  painted  over  the  granulations  with  a  brush, 
and  at  once  washed  off  with  warm  water,  and  if  this  is  well  borne,  and 
causes  a  subsidence  of  the  inflammatory  s3Tiiptoms,  we  may,  in  the 


CHRONIC   GRANULATIOXS.  53 

coiirse  of  a  day  or  two,  pass  over  to  the  use  of  the  stronger  caustics. 
But  if  any  infiUralions  or  ulcers  of  the  cornea  exist,  the  acetate  of  lead 
should  never  be  used,  as  it  will  be  precipitated  upon  the  cornea,  and 
give  rise  to  very  marked  «tains.  Von  Graefe*  strongly  recommends 
chlorine  water  for  the  purpose  of  paving  the  way  for  the  use  of  stronger 
caustics  in  acute  granulations. 

When  the  crayon  of  nitrate  of  silver  and  potash  is  applied,  it  should 
be  at  once  neutralized  by  the  application  of  salt  and  water.  As  a  rule 
the  cautei'ization  should  not  be  repeated  more  frequently  than  every  48 
hours.  Great  care  must  be  taken  if  any  ulcers  of  the  cornea  exist,  for 
they  may  be  easily  aggravated  by  too  free  a  use  of  the  nitrate  of  silver. 
If  there  is  a  great  deal  of  irritation,  I  often  apply  atropine  drops  in  the 
interval  of  the  cauterization.  When  the  swelling  of  the  conjunctiva 
has  considerably  subsided,  and  the  purulent  discharge  diminished,  the 
sulphate  of  copper  in  substance,  or  a  coUyrium  of  acetate  of  lead  may 
be  employed  with  advantage.  If  it  is  found  that,  together  with  the 
diminution  of  the  inflammation  and  the  size  of  the  papillae,  the  granu- 
lations assume  a  more  prominent  character  and  increase  in  size  and 
number,  this  tendency  to  a  neo-plastic-  formation  must  be  checked  at 
once,  and  their  absorption  hastened,  by  exciting  a  more  considerable 
amount  of  inflammation  by  means  of  a  freer  use  of  sonae  caustic,  espe- 
cially the  sulphate  of  copper,  which  possesses  the  great  advantage  of 
increasing  the  inflammation  without  giving  rise  to  thick  firm  eschars. 

CHRONIC   GRANULATIONS. 

Instead  of  the  very  pronounced  symptoms  of  irritation  and  inflam- 
mation which  are  met  with  in  acute  granular  ophthalmia,  the  inflam- 
mation accompanying  the  chronic  form  is  often  very  slight,  and  may, 
indeed,  be  almost  absent  at  the  commencement  of  the  afiection.  So 
that,  in  fact,  persons  may  be  sufiering  from  chronic  granulations  with- 
out being  aware  that  there  is  anything  particular  the  matter  with  their 
eyes  ;  the  eyelids  being  only  a  little  glued  together  in  the  morning,  or 
there  being  perhaps  a  slight  feeling  of  roughness  under  the  eyelids.  At 
the  same  time,  the  upper  lid  may  hang  down  somewhat,  its  natural 
folds  being  more  or  less  obliterated,  and  the  palpebral  aperture  conse- 
quently narrowed.  Duiing  all  this  time  the  conjunctival  inflammation 
may  be  almost  absent ;  indeed,  it  is  never  very  prominent,  or  in  pro- 
portion to  the  amount  of  the  granulations.  On  eversion  of  the  lids,  we 
at  once  notice  the  presence  of  the  granulations  in  the  form  of  small 
greyish- white  bodies,  like  tapioca  grains,  more  especially  at  the  retro- 
tarsal  fold,  and  in  the  vicinity  of  the  angles  of  the  eye.     They  may 

*  "  A.  f.  O.,"  X,  2,  197. 


54  DISEASES   OF   THE   CONJUNCTIVA. 

also  appear  on  tlie  palpebral  conjunctiva,  which  is  somewhat  injected 
and  swollen.  In  this  situation,  however,  their  size  and  number  are  less 
than  at  the  retro-tarsal  fold.  These  may  be  termed  "  simple  granula- 
tions," or,  according  to  Stellwag,  "  granular  trachoma."  Generally, 
however,  this  condition  is  soon  followed  by  inflammatory  sympt<ftns. 
The  conjunctiva  becomes  vascular,  thickened,  and  swollen,  and  the 
papillae  hyper trophied  and  prominent,  having  the  granulations  scattered 
between  them.  Here,  therefore,  we  have  true  granulations  existing 
side  by  side  with  the  swoUen  papillae,  and  hence  Stellwag  calls  this 
form  "mixed  granulations."  The  lids  are  more  or  less  pulpy,  the 
conjunctiva  red  and  swollen,  especially  in  the  retro-tarsal  region,  and 
there  is,  perhaps,  some  chemosis  round  the  cornea.  The  discharge, 
which  was  at  first  thin  and  Avatery,  with  only  a  few  yellow  flakes  sus- 
pended in  it,  becomes  thicker,  more  copious,  and  of  a  muco-purulent 
character.  The  eyes  are  very  irritable,  and  the  patient  experiences  a 
sensation  as  of  grit  or  sand  in  them,  especially  under  the  upper  lid,  and 
is  finable  to  expose  them  to  wind,  bright  glare,  dflst,  or  to  long  con- 
tinued work,  without  their  becoming  very  red,  wateTy,  and  inflamed. 

But  all  these  symptoms  vary  considerably  in  intensity,  according  to 
the  degree  of  the  accompanying  conjunctival  inflammation.  Some- 
times this  assumes  a  mild  catarrhal  form ;  in  other  cases  it  is  more 
severe  and  of  a  purulent  type.  The  course  of  the  disease  is  often  ex- 
tremely protracted,  extending  over  many  months,  or  even  years.  A 
source  of  danger  and  great  annoyance  and  discomfort  is  the  tendency 
to  relapses,  the  intensity  of  which  also  varies.  Thus  a  mild  attack  of 
chronic  mixed  granulations  may  be  nearly  cured,  when  from  an  expo- 
sure to  some  irritating  cause,"  a  relapse  occurs,  accompanied,  perhaps,  by 
a  more  severe  form  of  conjunctivitis  than  the  original  one,  and  a  fresh 
crop  of  granulations  appears  before  the  former  ones  have  been 
absorbed.  These  inflammatory  symptoms  are,  however,  rather  due 
to  a  renewed  swelKng  of  the  jDapillte  than  to  a  new  formation  of 
granulations.  Sometimes  these  relapses  are  accompanied  by  con- 
siderable infiltrations  of  the  cornea.  Such  relapses  may  occur  again 
and  again,  leaving  the  eye  each  time  in  a  worse  condition,  and  gradually 
giving  rise  to  various  serious  complications,  such  as  pannus,  trichiasis, 
entropion,  &c. 

If  the  attack  is  severe,  and  the  crop  of  granulations  very  con- 
siderable, the  infiltration  but  too  often  extends  from  the  surface  to  the 
substance  of  the  conjunctiva.  The  granulations  then  become  more 
velvety,  red,  prominent,  and  diffused  in  appearance,  (hence  the  "  dif- 
fuse trachoma"  of  Stellwag),  and  are  often  divided  by  deep  chiuks.  They 
are,  therefore,  less  distinguishable  from  the  papilla";,  especially  as  the 
latter  often  assume  a  bi'owuish-red  colour,  and  their  epithelial  layer 
becomes  somewhat  thickened. 


CHRONIC   GRANULATIOXS.  55 

If  the  development  of  the  gTanulatlons  cannot  be  checked,  and  they 
extend  deeply  into  the  stroma  of  the  conjunctiva,  the  latter  often  con- 
tracts, atrophies,  and  becomes  gradually  changed  into  a  kind  of  fibrous 
cicatricial  tissue.  These  changes  may  even  extend  to  the  cartilage, 
and  the  cicatrices  lend  a  peculiar  glistening  or  tendinous  appearance  to 
the  sui'face  of  the  conjunctiva.  We  see  the  latter  occupied  by  narrow 
tendinous  streaks,  the  longest  and  most  marked  generally  running 
parallel  to,  and  about  one  Kne  from  the  edge  of  the  lid.  Other  ten- 
dinous streaks  extend  in  a  reticulated  manner  towards  the  retro-tarsal 
fold.  But  if  the  atrophy  of  the  conjunctiva  and  cartilage  is  very 
considerable,  the  blood-vessels  gradually  become  obliterated,  and  the 
surface  of  the  conjunctiva  then  assumes  a  pale,  waxy,  uniformly  ten- 
dinous appearance,  the  papillos,  follicles,  and  finally  the  Meibomian 
glands  becoming  destroyed.  It  is  important  to  remember  that  too  free 
a  use  of  caustics  (especially  the  nitrate  of  silver  in  substance  or  in 
strong  solution)  will  destroy  the  delicate  structure  of  the  conjunctiva, 
and  produce  more  or  less  extensive  cicatrices. 

These  changes  often  extend  to  the  retro-tarsal  fold,  which  becomes 
contracted  and  tendinous,  so  that  its  free  border  is  shortened  and 
rounded.  It  no  longer  springs  into  folds  at  the  point  where  it  is 
reflected  from  the  lid  on  to  the  eyeball,  but,  on  account  of  this  short- 
ening, it  passes  almost  straight  on,  so  that  the  fold  or  cul  de  sac 
which  should  exist  at  this  point  is  obliterated.  This  condition  has 
been  termed  symblepharon  posterius.  If  it  is  very  considerable,  the 
lids  cannot  be  completely  closed,  and  thus  a  certain  degree  of  lagoph- 
thalmos  may  be  produced. 

These  changes  in  the  conjunctiva  are  of  coiu'se  accompanied  by  an 
alteration  and  diminution  in  its  normal  secretions,  so  that  its  surface 
becomes  dry,  rough,  and  scaly.  This  dryness  (xeropthalmia)  is  often 
increased  by  the  narrowing  or  even  obliteration  of  the  ducts  of  the 
lachrymal  gland,  by  the  inflammation  of  this  portion  of  the  con- 
junctiva. 

On  account  of  the  atrophy  and  contraction  of  the  conjunctiva  and 
tarsal  cartilage,  the  latter  becomes  shortened  and  incurved.  If  this  be 
but  slight,  it  may  only  produce  an  inversion  of  the  eyelashes  (trichiasis), 
which  now  sweep  and  rub  against  the  siu-face  of  the  cornea.  This 
inversion  may  be  confined  to  one  portion  of  the  lashes,  or  extend  to  the 
whole  row.  If  the  contraction  of  the  cartilage  is  considerable,  not  only 
the  eyelashes,  but  the  free  edge  of  the  lid  will  be  rolled  in,  and  thus  an 
entropion  will  be  produced.  The  constant  fiiction  of  the  lashes  and 
the  edge  of  the  eyelid  against  the  cornea,  irritates  the  latter,  and  soon 
gives  rise  to  superficial  vascular  corneitis  (pannus).  This  pannus 
may  be  termed  "traumatic"  (Arlt),  being  produced  by  the  friction  of 
the  inverted  lashes,  or  of  prominent  granulations  or  papillte,  &c.,  in 


56  DISEASES   OF   THE   CONJUNCTIVA. 

contradistinction  to  the  pannus,  which  is  due  to  an  extension  of  the  granu- 
lations on  to  the  cornea.  The  differential  diagnosis  between  these  two 
forms  is  generally  not  difficult.  In  the  latter,  we  can  trace  the  exten- 
sion of  the  disease  from  the  ocular  conjunctiva  on  to  the  cornea.  Small, 
round,  elevated,  gTcy  infiltrations  are  formed  on  its  surface  just  beneath 
the  epithehum,  and  extend  over  a  considerable  portion,  or  even  the 
whole  of  the  cornea.  Between  these  little  nodules,  blood-vessels  appear 
in  more  or  less  considerable  number.  These  infiltrations  often  leave 
behind  them  depressions  or  small  ulcers  on  the  surface  of  the  cornea. 
The  traumatic  pannus  almost  always  commences  at  the  upper  portion 
of  the  cornea,  extending  from  the  periphery.  This  is  due  to  the  fact, 
that  the  granulations  are  generally  more  prominent,  and  trichiasis  is 
more  frequent  in  the  upper  lid  than  in  the  lower.  The  pannus  fre- 
quently remains  confined  to  the  upper  portion  of  the  cornea,  the  lower 
continuing  transparent. 

Chronic  granulations  occur  most  frequently  in  adults,  and  are  but 
seldom  met  with  in  children,  or  the  very  aged.  Both  eyes  generally 
become  affected  either  at  the  outset,  or  after  a  time.  It  has  been 
maintained  by  some  ophthalmic  surgeons  of  eminence  (more  especially 
Arlt),  that  the  disease  is  often  due  to  constitutional  causes,  particu- 
larly scrofula.  This  does  not,  however,  appear  to  be  the  case,  although 
it  must  be  conceded,  that  it  is  frequently  met  with  in  weakly,  cachectic, 
and  scrofulous  individuals.  But  ill-health  is,  I  think,  rather  the  efiect 
than  the  cause,  for  the  very  protracted  course  of  the  disease  is  sui^e  to 
tell  more  or  less  severely  upon  the  health  and  spirits  of  the  patient. 

Defective  hygiene  and  contagion  are  also  the  chief  causes  of  chronic 
granulations.  The  muco-purulent  discharge  is  very  contagious,  and 
may  re-produce  a  similar  afiection,  or  it  may  cause  catarrhal,  purulent, 
or  even  diphtheritic  ophthalmia,  just  as,  conversely,  these  diseases  m.ay 
produce  granular  lids. 

It  is  probable  that,  as  in  purulent  ophthalmia,  the  disease  may  also 
be  propagated  by  the  air,  more  especially  if  it  is  accompanied  by  severe 
purulent  discharge,  and  the  cases  are  crowded  together  in  small,  close, 
ill- ventilated  rooms.  The  disease  may  occur  epidemically  and  endemi- 
cally.  It  spreads  rapidly  amongst  the  inhabitants  of  closely- crowded 
dwellings,  such  as  barracks  and  workhouses.  It  is  very  prevalent  amongst 
certain  nationalities,  where  the  people  are  crowded  together  for  a  length 
of  time  in  small  dirty  cabins,  filled,  perhaps,  with  smoke  and  ammoniacal 
exhalations.  Thus  it  is  very  common  amongst  the  poorer  Irish,  and 
also  am.ongst  the  Russian  peasants  (Wecker). 

The  i^rognosis  of  chronic  granular  ophthalmia  may  be  favourable,  if 
the  granulations  have  been  but  limited  in  number,  and  the  patient  has 
been  treated  from  the  outset.  It  must,  however,  be  always  remem- 
bered that  the  course  of  the  disease,  even  in  the  most  favourable  cases. 


CHRONIC   GRANULATIONS.  57 

is  apt  to  be  very  protracted.  Tins  will  be  more  esjoecially  the  ease,  if 
tlie  granulations  have  appeared  in  considerable  quantity ;  if  they  have 
invaded  the  stroma  of  the  conjunctiva,  and  if  there  is  a  tendency  to 
relapses.  For  then  serious  complications,  such  as  trichiasis,  entro- 
pion, and  pannus,  are  likely  to  occur,  and  will  not  only  aggravate  the 
symptoms,  but  greatly  retard  the  cure. 

In  the  treatment  of  this  disease,  our  first  care  must  be  to  place  the 
patients  under  the  most  favourable  sanitary  conditions.  They  should 
take  a  good  deal  of  out-door  exercise,  their  eyes  being  protected 
against  wind,  dust,  and  bright  light  by  blue  glasses.  They  should  be 
warned  not  to  expose  themselves  to  any  irritating  causes,  as,  for 
instance,  tobacco  smoke.  I  have  often  known  the  disease  aggravated 
and  kept  up  by  the  patient  spending  much  time  in  a  room  filled  with 
tobacco  smoke.  For  this  reason  no  smoking  should  be  allowed,  except 
in  the  open  arr,  and  then  only  to  a  limited  extent.  The  general  health 
must  also  be  attended  to.  Not  only  may  the  patient  be  naturally  weak 
and  feeble,  but  the  severity  and  protracted  course  of  the  disease  are  but 
too  likely  to  affect  the  health,  and  at  the  same  time  to  exercise  a  most 
depressing  influence  upon  the  mind.  The  diet  should  be  nutritious, 
and  easily  digestible,  and  malt  liquor  and  wine  will  generally  be  very 
beneficial.  If  the  patient  is  scrofu.lous,  or  weak  and  feeble,  cod  liver 
oil,  steel,  and  quinine  should  be  freely  given,  and  every  care  taken  to 
invigorate  the  constitution  as  much  as  possible  by  open  air  exercise, 
sea-bathing,  or  even  a  voyage. 

In  our  local  treatment  we  must  be  chiefly  influenced  by  the  fact, 
that  the  maintenance  of  a  certain  degree  of  inflammation  of  the  con- 
junctiva is  necessary  and  desirable,  in  order  to  produce  and  hasten  the 
absorption  of  the  grantdations.  Our  chief  efibrts  must,  therefore,  be 
directed  to  maintain  the  requisite  degree  of  inflammation,  and  so  to 
balance  it  that  it  shall  not  on  the  one  hand  be  too  considerable,  nor  on 
the  other  too  shght  for  promoting  the  absorption. 

The  greatest  stress  must  be  laid  upon  the  fact,  as  Arlt  and  Stromeyer 
remind  us,  that  the  purpose  of  the  cauterization  is  not  that  of  chemically 
destroying  the  granulations,  for  this  would  lead  to  great  and  lasting 
injury  of  the  conjunctiva  from  the  destruction  of  its  secreting  organs, 
and  the  formation  of  dense  cicatrices ;  but,  its  object  is  to  maintain  a 
certain  degree  of  hypergemia  and  inflammation  of  the  conjunctiva,  in 
order  to  hasten  the  absorption  of  the  granulations.  The  nature  and 
strength  of  the  caustic  must  vary  with  the  effect  we  desire  to  produce. 
If  there  is  much  swelling  of  the  conjunctiva  and  papillae,  together  with 
a  thick,  copious  muco-purulent  discharge,  the  crayon  of  nitrate  of  silver 
and  potash  should  be  applied,  its  effect  being  at  once  neutralized  by 
the  solution  of  salt  and  water.  The  cauterization  may  be  repeated 
every  48  houi's.     If  the  patient  cannot  be  seen  sufficiently  frequently 


58  DISEASES   OF   THE   CONJUNCTIVA. 

for  this,  he  should  use  a  collyrmm  of  nitrate  of  silver  (gr.  ij — iv  ad  3j)j 
or  of  sulphate  of  copper  of  the  same  strength,  two  or  three  times  daily. 
In  these  cases  we  may  also  first  try  the  effect  of  a  collyrinm  of  acetate 
of  lead,  or  the  chlorine  water,  in  order  to  see  if  the  conjunctiva  will  bear 
the  nitrate  of  silver.  The  use  of  very  strong  solutions  of  nitrate  of 
silver  (gr.  x — xx  ad  3J.)  are  not  judicious,  as  they  are  but  too  likely 
to  destroy  the  granulations,  and  with  them  the  normal  structure  of  the 
conjunctiva,  instead  of  simply  favoua^ing  their  absorption.  I  think  the 
crayon  of  nitrate  of  silver  or  copper  is  always  to  be  preferred  to  the  use 
of  collyria,  as  we  can  regulate  and  limit  the  effect  of  the  cauterization 
according  to  oui'  wish,  confining  it,  if  necessary,  chiefly  or  entirely  to 
certain  portions  of  the  conjunctiva.  If  there  is  considerable  swelling  of 
the  conjunctiva,  especially  at  the  retro-tarsal  fold,  superficial  scarification 
may  be  employed  with  much  advantage.  After  the  cauterization  cold 
compresses  should  always  be  applied  to  the  eyelids,  in  order  to 
diminish  the  inflammatory  reaction,  or  the  cold  douche  or  pulverizer 
may  be  employed.  If  the  conjunctivitis  is  so  slight  as  not  to  produce  the 
absorption  of  the  granulations,  but  rather  to  encourage  their  develop- 
ment, it  will  be  necessary  to  increase  the  hypersemia  and  inflammatory 
swelling  of  the  conjunctiva.  The  repeated  application  of  sulphate  of 
copper  in  substance  is  very  efiectual  for  this  purj)0se.  The  same  effect 
may  also  be  produced  by  the  application  of  warm  compresses  to  the 
eyelids.  Von  Grraefe*  has  found  this  treatment  very  successful, 
especially  in  those  cases  in  which  the  granulations  tend  to  extend 
deeply  into  the  conjunctiva,  and  in  which  there  is  not  a  sufficient  degree 
of  liyperEemia  and  swelling  of  this  membrane.  These  warm  compresses 
should,  however,  only  be  applied  for  a  limited  period,  otherwise  they 
may  produce  too  considerable  an  inflammation  and  too  great  an  irritability 
of  the  eye. 

In  treating  chronic  granulations,  it  will  be  necessary  occasionally  to 
change  the  caustic,  as  it  loses  its  effect  after  a  time,  from  the  con- 
junctiva becoming  accustomed  to  it.  Thus  alum,  acetate  of  lead,  or 
tannin,  may  be  substituted  with  advantage  for  the  nitrate  of  silver  and 
sulphate  of  copper.  In  some  cases  the  acetate  of  lead  should  be  rubbed 
in  (finely  powdered)  between  the  granulations.  This  treatment,  which 
was  first  adopted  by  Buys,t  has  been  practised  with  great  success, 
especially  in  Belgium.  I  have  employed  it  with  much  benefit  in  those 
cases  in  which,  together  with  but  a  slight  secretion  and  lachrymation, 
the  granulations  are  prominent  and  fleshy,  being  ari'anged  in  rows  with 
deep  furrows  or  chinks  between  them.  Finely  powdered  acetate  of 
lead  should  be  freely  rubbed  into  these  furrows  until  they  are  quite 
filled   up.     The  effect  of  this  is,  so  to  speak,  to   choke  the  granula- 

*  "  A.  f.  O.,"  vi,  2,  11.7. 

t  Frencli  Translation  of  Mackenzie's  Treatise,  by  Warlomont,  1,  748. 


CHRONIC   GRANULATIONS.  59 

tions,  tlieir  vitality  is  impaired,  and  tlicy  gradually  dwindle  down  in 
size  and  disappear.  After  the  application,  the  conjunctiva  looks  marbled 
or  tattoed  of  a  red  and  white  colour,  the  chinks  are  filled  up,  and  it  soon 
becomes  smooth  and  even.  An  important  fact  in  connexion  with  this 
treatment  is,  that  the  discharge  is  now  no  longer  contagious  ;  at  least  in 
Belg-ium  it  is  always  considered,  when  the  acetate  of  lead  has  been 
rubbed  in,  that  the  patients  may  go  with  impunity  amongst  healthy 
persons,  so  that  soldiers  affected  with  granular  lids  need  no  longer  be 
confined  and  separated  fi-om  the  others,  but  may,  if  they  are  able, 
resume  their  duties  without  danger  of  spreading  the  disease.  The 
acetate  of  lead  is  best  apphed  in  the  following  manner : — The  eyelids 
having  been  thoroughly  everted  and  the  retro-tarsal  fold  brought  well 
into  "V'iew,  a  small  portion  of  very  finely  powdered  acetate  of  lead  is  then 
taken  up  in  a  small  curette  and  dusted  over  the  granulations,  being 
well  rubbed  into  the  chinks  so  as  to  fill  them  up.  The  watery  dis- 
charge from  the  conjunctiva  forms  the  powder  into  a  thin  plasma, 
which  runs  through  and  fills  up  the  furrows  between  the  granulations. 
When  it  has  been  applied  to  every  portion  of  the  granular  conjunctiva, 
a  small  stream  of  cold  water,  either  from  a  sponge  or  an  india-rubber 
ball  syringe,  should  be  ruade  to  play  upon  the  conjunctiva,  in  order  to 
wash  away  any  superfluous  quantity  of  the  powder,  which  comes  away 
in  small  white  flakes.  Both  eyelids  may  be  everted  at  the  same  time, 
so  as  to  fold  over  and  protect  the  cornea,  the  powder  being  rubbed  over 
both  eyelids,  and  the  stream  of  water  applied  before  they  are  replaced. 
But  if  the  simultaneous  eversion  of  both  lids  is  difficult,  or  the  patient 
veiy  restless  and  unruly,  it  is  better  to  evert  one  lid  at  a  time.  It  is 
best  to  commence  with  the  lower  lid,  for  if  the  lead  be  applied  first  to 
the  upper,  the  lower  becomes  reddened  and  bathed  in  tears,  so  that  it 
will  not  only  be  difficult  to  see  the  chinks,  but  the  powder  will  be 
readily  washed  away  by  the  tears,  whereas  the  conjunctiva  of  the  upper 
lid,  from  its  greater  expanse,  can  be  more  readily  dried,  and  the  tears 
are  hence  of  less  inconvenience. 

Directly  after  the  application,  there  is  an  increased  flow  of  tears, 
the  ocular  conjunctiva  becomes  injected,  and  this  is  accompanied 
perhaps  by  considerable  u^ritation,  heat,  and  smarting  in  the  eye,  but 
these  symptoms  will  soon  yield  to  the  application  of  cold  compresses. 
In  about  half  an  hour,  the  lids  should  be  everted  and  the  conjimctiva 
again  washed  by  a  stream  of  water,  in  order  that  any  remains  of  the 
lead  may  be  removed.  The  conjunctiva  will  now  be  more  smooth  and 
even,  the  chinks  between  the  granulations  being  filled  up  and  obliterated 
by  the  powder.  If  the  application  has  been  insufficient  or  too  super- 
ficial, the  granulations  will  reappear  after  a  time  and  increase  in  size 
and  prominence,  rendering  a  fresh  application  of  the  remedy  necessary. 
If  the  acetate  of  lead  is  carefully  applied  and  the  surplus  well  washed 


60  DISEASES   OF   THE   CONJUNCTIVA. 

away,  I  cannot  say  that  I  have  ever  seen  any  disadvantage  aiise  from 
its  employment,  nor  have  1  found  that  it  roughens  the  lids  and  thus 
irritates  the  surface  of  the  cornea.  The  best  mode  of  applying  the 
solution  of  the  acetate  of  lead  is  to  evert  the  Hds,  and  after  drying  the 
conjunctiva  with  a  piece  of  linen,  to  apply  it  with  a  small  brush  to  the 
granulations,  this  being  neutralized  after  a  few  seconds  with  tepid  water. 
The  strength  of  the  solution  should  vary  from  6  to  10  or  20  grains  to 
the  ounce,  according  to  the  condition  of  the  conjunctiva,  and  it  should 
be  apphed  every  day  or  every  other  day. 

I  must  strongly  object  to  the  application  of  undiluted  liquor  potassae 
to  the  granulations,  as  this  not  only  more  or  less  destroys  the  stroma 
of  the  conjunctiva,  but  gives  rise  to  very  considerable  cicatrices,  leading 
to  entropion,  etc. 

Should  any  ulcers  of  the  cornea  exist,  the  treatment  of  the  conjunc- 
tivitis by  caustics  must  be  continued,  but  atropine  should  be  apphed  in 
the  intervals.  The  application  of  a  firm  compress  bandage  often  acts 
very  advantageously  in  checking  the  growth  of  the  granulations,  and 
hastening  their  absorption ;  but  other  local  remedies  must  be  at  the 
same  time  applied.  It  has  even  been  suggested  to  keep  up  a  consider- 
able degree  of  compression  by  ivory  plates  adjusted  to  the  lids.* 

The  treatment  of  the  pannus  must  vary  according  to  its  cause,  its 
degree,  and  length  of  existence.  If  it  be  dependent  upon  the  friction  of 
inverted  lashes,  prominent  granulations  or  papilla?,  or  upon  entropion, 
these  afiections  must  be  treated,  and  when  they  are  cui^ed  the  pannus 
will  soon  disappear.  But  if  the  granular  lids  and  the  pannus  have 
become  very  chronic,  they  may  set  the  most  obstinate  defiance  to  the 
most  varied  treatment.  Caustics  and  stimiJant  applications  of  every 
kind  may  be  tried,  and  yet  the  disease  prove  intractable.  In  some 
cases,  in  which  the  pannus  was  not  too  dense  and  vascular,  I  have 
found  a  good  deal  of  benefit  from  a  collyrium  composed  of  1  part  of 
oil  of  turpentine  to  2  or  4  parts  of  olive  oil.  A  drop  of  it  should  be 
applied  once  or  twice  daily  to  the  inside  of  the  lid.  This  collyrium  was, 
I  believe,  first  recommended  by  Bonders.  If,  on  the  disappearance  of 
the  pannus,  we  find  the  curvature  of  the  cornea  considerably  altered,  or 
a  central  opacity  remain,  it  may  be  necessary  to  make  an  artificial 
pupil,  either  by  an  iridectomy  or  an  iridodesis. 

Von  Graefef  has  found  great  benefit  from  chlorine  water  in  cases  of 
even  severe  complete  pannus.  He  especially  mentions  two  cases  in 
which  the  pannus  was  so  advanced  that  the  patients  could  only  distinguish 
light  from  dark,  and  were  quite  unable  to  count  fingers.  In  both,  not 
only  had  various  caustics,  such  as  nitrate  of  silver,  sulphate  of  copper, 
acetate  of  lead,  been  applied  for  maiiy  months  without  avail,  but  syn- 

*  Vide  Dr.  Stokes'  paper  on  this  subject,  "  Dub.  Quart.  Journal  Med.  Science," 
xli.,  38.  t  "  A.  f.  O.,"  X,  2,  198. 


CHRONIC   GRANULATIONS.  61 

dectomy  liad  been  performed,  and  in  one  inoculation,  without  any- 
beneficial  result.  After  using  the  chlorine  water  for  six  or  eight  weeks, 
they  were  both  so  much  improved  as  to  be  able  to  find  their  way  about 
tolerably  well.  In  other  less  severe  cases  of  pannus  he  has  also  expe- 
rienced much  benefit  from  its  use. 

For  very  inveterate  cases  of  pannus,  more  especially  if  they  only 
involve  a  portion  of  the  cornea,  syndectomy  may  be  tried.  This 
operation,  which  was  first  introduced  by  Dr.  Furnari,*  proves  useful 
in  cases  of  inveterate  pannus,  in  which  a  portion  of  the  cornea  is  clear, 
so  that  it  would  not  be  safe  to  perform  inoculation,  or,  if  the  latter  is  for 
some  reason  inapplicable,  in  cases  of  complete  pannus.  The  object  of 
the  operation  is  to  cut  off  the  supply  of  blood  from  the  cornea  by  a 
division  and  part  removal,  not  only  of  the  conjunctival  but  also  of  the 
subconjunctival  vessels.  It  is  a  less  dangerous  and  troublesome 
proceeding  than  inoculation.  It  must,  however,  be  also  admitted  that 
it  is  not  always  successful,  the  cases  improving  perhaps  somewhat  at 
first,  and  then  a  relapse  takes  place. 

Syndectomy  is  to  be  performed  in  the  following  manner: — The 
patient  should  be  placed  thoroughly  under  the  influence  of  chloroform, 
as  the  operation  is  very  painful  and  protracted,  and  the  eyelids  should 
be  kept  apart  by  the  stop  speculum.  The  operator  then  seizes  with  a 
pair  of  forceps  a  portion  of  the  conjunctiva  and  subconjunctival  tissue, 
near  the  cornea,  so  as  to  fix  the  eye  steadily.  He  next  with  a  pair  of 
curved  scissors  makes  a  circular  incision  through  the  conjunctiva,  all 
round  the  cornea,  and  about  an  eighth  of  an  inch  from  the  edge  of  the 
latter,  and  parallel  to  it.  This  circular  band  is  then  prepared  off",  and 
excised  close  to  the  edge  of  the  cornea,  so  that  a  wide  circle  of  con- 
junctiva may  be  removed  all  round  the  cornea.  For  the  purpose  of 
more  easily  rotating  the  eye,  two  small  portions  of  conjunctiva  should 
be  left  standing  near  the  cornea  until  the  operation  is  completely 
finished,  when  they  are  to  be  snipped  ofi".  A  circular  portion  of  the 
subconjunctival  tissue,  corresponding  to  the  wound  in  the  conjunctiva, 
is  next  to  be  removed,  quite  close  to  the  sclerotic,  so  as  to  bare  the 
latter  completely ;  if  small  portions  of  subconjunctival  tissue  remain 
adhering  to  it,  they  may  be  scraped  ofi"  with  the  edge  of  a  cataract  or 
iridectomy  knife.  Some  of  the  larger  vessels  upon  the  cornea  may  also 
be  divided  near  its  edge.  Dr.  Fiu'nari  advises  that  the  exposed  sclerotic 
should  be  cauterized  with  nitrate  of  silver.  This  is,  however,  a  most 
dangerous  proceeding,  as  it  is  but  too  likely  to  produce  inflammation 
and  sloughing  of  the  sclerotic  and  cornea.     Cold  compresses  should  be 

*  "  Gazette  Medicale,"  1862,  No.  4,  etc.  ;  vide  also  an  Article  upon  the  subject 
by  Mr.  Bader,  "  Roj.  Lond.  Oplith.  Hosp.  Reports,"  iv,  22.  This  operation  has 
received  various  names  ;  at  one  time  it  was  termed  Circumcision  of  the  cornea.  It 
is  now  generally  called  either  Syndectomy  or  Peritomy. 


62  DISEASES   OF   THE  CONJUNCTIVA. 

applied,  until  the  symptoms  of  inflammatory  reaction  have  subsided. 
These  are,  as  a  rule,  but  moderate,  and  the  photophobia  pain  and  lachry- 
mation  generally  disappear  in  about  48  or  60  hours.  It  is  wise  to  keep 
the  patients  in  the  hospital  for  a  few  days,  so  that,  if  severe  inflamma- 
tory symptoms  should  supei'vene,  they  may  be  treated  at  once. 

In  those  cases  of  inveterate  jDannus  in  which  the  latter  is  thick,  very 
vascular,  and  covers  the  whole  of  the  cornea,  and  in  which,  on  account 
of  the  cicatricial  changes  in  the  conjunctiva,  it  is  impossible  to  excite 
sufficient  hypera3mia  and  swelling  of  the  conjunctiva  for  the  absorption 
of  the  granulation,  it  may  be  necessary  to  produce  a  purulent  inflamma- 
tion of  the  conjunctiva  by  the  inoculation  of  pus,  in  order  that,  if 
possible,  the  granulations  may  be  absorbed  and  the  cornea  cleared  during 
the  progress  of  the  inflammation.  This  proceeding,  which  was  first 
advocated  by  Piringer,  has  long  been  extensively  and  successfully 
practised  in  Belgium,  where  granulations  are  very  common  amongsfe- 
the  soldiers.  In  England  it  has  also  been  very  largely  and  successfully 
employed,  more  especially  at  the  Royal  London  Ophthalmic  Hospital, 
Moorfields,  where  Mr.  Bader  first  introduced  it.  I  have  seen  many 
admirable  cures  produced  by  it,  and  patients  restored  to  the  enjoyment 
of  excellent  sight  (some  being  able  to  read  No.  1  of  Jager)  who  had 
been  sufiering  from  so  dense  a  pannus  that  they  were  unable  even  to 
count  fingers.  In  many  of  these  cases  most  other  remedies  had  been 
tried  without  avail,  and  I  know  of  no  other  treatment  which  would 
have  restored  their  sight.  The  chief  danger  is,  of  course,  that  the  puru- 
lent inflammation  which  is  induced,  should  be  so  severe  as  to  produce 
suppuration  of  the  cornea  and  loss  of  the  eye.  But  it  is  surprising 
what  a  degree  of  inflammation  a  very  vascular  and  completely  pannous 
cornea  will  bear  with  impunity,  and  be,  perhaps,  finally  restored  to 
almost  normal  transparency.  It  may  be  laid  down  as  a  rule,  that  the 
more  vascular  the  cornea  is,  the  less  danger  is  there  of  its  sloughing, 
for  the  numerous  blood-vessels  on  its  surface  will  maintain  its  vitality 
during  the  purulent  inflammation.  Inoculation  is,  therefore,  much  less 
safe  where  the  vascularity  of  the  cornea  is  but  moderate,  and  is  inad- 
missible if  a  portion  of  it  remains  transparent.  Another  danger 
of  inoculation  is,  that  the  matter,  instead  of  setting  up  j)urulent 
ophthalmia,  may  give  rise  to  diphtheritic  conjunctivitis.  Happily  this 
danger  is  but  very  slight  in  England,  but  we  have  seen  that,  in  certain 
parts  of  the  continent,  more  especially  Berlin,  this  affection  is  but  of  too 
common  occurrence,  and  that  the  mild  forms  of  conjunctivitis  often 
produce  the  most  virulent  form  of  diphtheritic  ophthalmia.  For  this 
reason,  it  is  there  hardly  safe  to  inoculate  a  case  of  pannus  with  even 
the  mildest  purulent  matter,  for  we  have  no  guarantee  that  it  may  not 
give  rise  to  diphtheritis.  Von  Gracfe  lias  called  especial  attention 
to  this  fact,  and  has  been  obliged,  in  consideration  of  so  great  a  risk, 


CHRONIC   GRANULATIONS.  63 

to  abandon  almost  entirely  the  employment  of  inoculation  in  the  treat- 
ment of  panniis.  In  England  the  occurrence  of  diphtlicritis  is  extremely 
rare,  and  I  have  not  seen  a  single  case  of  inoculation  in  which  it  has 
ensued. 

Many  surgeons  are  still  very  much  afraid  of  inoculation,  but  I 
think,  when  we  consider  how  utterly  hopeless  most  cases  of  severe 
chronic  pannus  are,  that  we  are  justified  in  strongly  recommending 
the  patient  to  run  some  slight  degree  of  risk  for  the  chance  of 
obtaining  a  useful  amount  of  sight.  I  do  not,  therefore,  hesitate  to 
employ  it  in  cases  of  inveterate,  complete,  vascular  pannus,  in  which 
the  other  remedies  have  been  tried  ^\ithout  avail,  for  in  such  we  must 
admit  that  it  is  our  last  resource,  and  that  no  other  chance  of  restoring 
the  sight  remains. 

Care  must,  however,  be  taken  in  the  choice  of  the  purulent  matter, 
and  in  regulating  its  strength  according  to  the  exigencies  of  the  case. 
The  more  dense  and  vascular  the  pannus,  the  stronger  may  the  matter 
be.  The  best  and  safest  is  that  obtained  from  the  eyes  of  an  infant 
sufi'ering  from  purulent  ophthalmia,  more  especially  if  the  disease  is  in 
its  decline,  and  no  affection  of  the  cornea,  or  only  a  very  slight  one, 
exists.  Yellow  pus  is  more  active  and  powerful  than  the  whitish  dis- 
charge, as  is  also  that  taken  from  the  eye  dm-ing  the  acute  stage  of  the 
disease. 

The  matter  from  an  eye  suffering  from  inoculation  is  stronger  than 
that  from  an  infant,  as  its  activity  appears  to  be  increased  by  the  inocu- 
lation. Gonorrhoeal  matter  is  far  too  strong  and  dangerous.  Even  in 
the  worst  cases,  I  prefer  the  whitish  discharge  from  an  infant.  Mr.  Law- 
son,  who  has  had  very  great  experience  in  this  subject  of  inoculation, 
has  also  very  justly  pointed  out,*  that  in  using  gonorrhceal  matter 
there  is  the  risk  of  its  being  tainted  by  the  syphilitic  virus  through  a 
chancre  perhaps  existing  in  the  urethra. 

The  mode  of  inoculation  is  as  follows  : — A  drop  of  pus  from  the  eye 
of  an  infant  affected  with  purulent  ophthalmia  is  to  be  placed  with  the 
tip  of  the  finger  (or  a  camel's  hair  brush)  on  the  inside  of  the  lower 
eyelid,  and  left  there.  Within  24  hours  of  the  inoculation  the  eyelids 
generally  begin  to  swell  and  become  oedematous,  often  to  a  very  con- 
siderable degree ;  this  is  accompanied  by  more  or  less  irritabihty  of  the 
eye,  photophobia,  and  lachrymation.  In  the  course  of  three  or  four 
days  all  the  symptoms  of  an  acute  purulent  ophthalmia  set  iu,  together 
with  a  copious,  thick,  creamy  discharge.  The  disease  mostly  runs  its 
course  in  from  three  to  four  weeks,  by  the  end  of  which  time  the  cornea 
is  generally  much  more  clear,  and  the  granulations  diminished.  This 
improvement,  however,  continues  to  increase  for  many  weeks,  or  even 

*  "  Roy.  Lond.  Oplith.  IIosp.  Reports,"  iv,  p.  183. 


64  DISEASES  OF  THE  CONJUNCTIVA. 

months.  No  treatment  is  to  be  adopted  for  checking  the  course  of  the 
inflammation.  After  the  second  or  third  day  the  patient  may  be  per- 
mitted to  wipe  away  the  discharge  with  a  sponge  or  a  bit  of  linen,  so 
as  to  cleanse  the  eye.  But  however  severe  the  inflammation  may  be, 
it  must  be  allowed  to  run  its  course  unchecked  by  the  use  of  astrin- 
gent or  caustic  lotions. 

One  eye  should  be  inoculated  at  a  time,  the  other  being  carefully 
closed  by  the  hermetic  collodion  compress.  This  must  be  more  espe- 
cially done  if  this  eye  is  sound.  Indeed,  in  such  case  it  may  be  a 
question  whether  the  diseased  eye  should  be  inoculated  at  all,  for  fear 
that,  through  any  mischance  or  carelessness,  the  healthy  eye  should 
become  afiected.  In  deciding  this  point,  we  must  be  chiefly  guided  by 
individual  consideration.  The  compress  should  be  removed  every  day, 
in  order  that  the  eye  may  be  washed  and  cleansed,  during  which  pro- 
cess, of  course,  the  greatest  care  must  be  taken  that  no  matter  gets 
into  it. 

A  very  interesting  and  important  fact  has  been  pointed  out  by 
Mr.  Lawson,*  viz.,  that  a  prehminary  syndectomy  appears  to  render 
the  inoculation  a  safer  proceeding,  for  the  conjunctiva  and  subconjunc- 
tival tissue  having  been  removed  from  around  the  cornea,  the  intensity 
of  the  inflammation  at  this  point  is  greatly  diminished,  and  the  cornea 
less  apt  to  sufier.  In  cases,  therefore,  in  which  the  pannus  is  not  very 
vascular,  or  does  not  involve  the  whole  of  the  cornea,  and  where, 
therefore,  inoculation  might  prove  dangerous,  it  would  be  advisable  to 
precede  it  by  a  syndectomy,  and  then,  when  the  eye  has  quite  recovered 
from  this,  to  employ  inoculation. 

8.— PHLYCTENULAR    OPHTHALMIA. 

The  disease  is  generally  ushered  in  by  a  feeling  of  heat  and  itching 
in  the  eyelids,  and  a  watery  and  irritable  condition  of  the  eye.  These 
symptoms  of  irritation  increase  until  there  may  be  a  very  considerable 
amount  of  photophobia,  lachrymation,  and  pain  in  and  around  the  eye 
(ciliary  neuralgia).  The  latter,  however,  is  never  so  severe  when  the 
phlyctenulae  are  confined  to  the  conjunctiva,  as  when  they  also  invade 
the  cornea.  There  is  also  more  or  less  conjunctival  and  subconjunc- 
tival injection,  the  degree  and  extent  of  which  vary  with  the  intensity 
and  extent  of  the  disease.  Sometimes  the  injection  is  only  partial  and 
confined  to  a  certain  portion  of  the  ocular  conjunctiva.  We  then 
notice  a  triangular,  fan-like  bundle  of  conjunctival  vessels,  extending 
from  the  retro-tarsal  region  towards  the  edge  of  the  cornea.  The  base 
of  the  triangle  is  turned  towards  the  palpebree,  and  the  apex  is  at  the 

*  "  Roy.  Lond.  Oplith.  Hosp.  Reports,"  iv,  p.  185. 


PHLYCTENULAR   OPHTHALMIA.  G5 

cornea.  Beneath  the  conjunctival  injection  is  observed  a  correspond- 
ing rosy  zone  of  subconjunctival  vessels.  At  this  spot  there  is  also 
generally  a  slight  cedematous  swelling  of  the  conjunctiva  (serous 
chemosis).  At  the  apex  of  the  triangle  of  vessels,  one  or  more  small 
herpetic  vesicles  or  pustules  make  their  appearance,  which  are  semi- 
transparent,  or  of  a  yellowish- white  colour,  and  about  the  size  of  a 
small  millet  seed.  They  are  especially  apt  to  occur  at  the  outer  side 
of  the  cornea,  and  are  often  symmetrical,  being  formed  at  the  outer 
side  of  each  eye.  The  epithelium  which  covers  the  phlyctenula  is  soon 
shed,  leaving  a  small  excoriation  or  ulcer,  which  gradually  dwindles 
down  and  becomes  completely  absorbed.  In  other  cases  the  ulcer  in- 
creases somewhat  in  size  and  depth,  and  its  contents  become  yellow  and 
opaque;  but  after  a  time  it  is  covered  again  by  epithelium,  and  its  con- 
tents then  gradually  undergo  absorption.  With  the  appearance  of  the 
phlyctenula  the  symptoms  of  irritation  generally  diminish,  especially 
when  the  epithelium  is  shed  and  the  contents  of  the  vesicle  escape. 
As  the  latter  is  being  absorped  the  vascularity  decreases,  but  at  the 
same  time  the  conjunctiva  may  become  somewhat  swollen,  especially 
in  the  retro-tarsal  region,  and  this  is  accompanied  by  a  muco-purulent 
discharge ;  so  that  we  have  in  fact  a  combination  of  catarrhal  and 
phlyctenular  ophthalmia.  The  affection  may,  however,  from  the  outset 
have  this  mixed  character. 

If  the  phlyctenula3  are  not  confined  to  one  portion  of  the  ocular 
conjunctiva,  but  are  scattered  about  on  various  parts  of  it,  in  perhaps 
considerable  numbers,  the  vascularity  is  diffuse  and  well  marked.  The 
symptoms  of  irritation  are  more  pronounced,  and  the  ciliary  neuralgia, 
lachrymation,  and  photophobia  greater.  The  latter,  indeed,  is  some- 
times excessive  in  phlyctenular  ophthalmia,  more  especially  in  scrofu- 
lous children,  and  is  often  quite  disproportionate  to  the  amount  of  the 
vesicles.  The  phlyctenulae  frequently  form  at  the  edge  of  the  cornea, 
surrounding  it  like  a  x^ow  of  beads,  or  they  occur  at  the  limbus 
conjunctivae,  lying  partly  on  the  cornea  and  partly  on  the  conjiinctiva. 
Yery  often  the  affection  appears  simultaneously  on  the  conjunctiva 
and  the  cornea.  The  pustules  sometimes  increase  considerably  in  size 
and  depth,  the  inflammation  extending  to  the  subconjunctival  tissue 
(episcleritis),  and  even  perhaps  to  the  superficial  layers  of  the  sclerotic. 
The  coiTCsponding  portion  of  the  conjunctiva  and  subconjunctival 
tissue  are  then  often  very  vascular,  and  considerably  thickened  and 
swollen,  so  that  the  pustules  appear  situated  upon  a  prominent  base. 
The  vascularity  (especially  of  the  subconjunctival  tissue)  is  of  a 
pecuhar  dusky,  bluish-red  tinge,  which  is  very  easily  recognised. 
This  form  is  extremely  protracted  and  very  prone  to  relapses,  so  that 
many  months  may  elapse  before  it  is  cured.  When  the  pustules  are 
very  numerous,  it  has  been  termed p annus  herpeticus. 

V 


6H  DISEASES   OF   THE   CONJUNCTIVA. 

The  lyrognosis  of  phlyctenular  ophthalmia  is  generally  very  favour- 
able, especially  if  the  case  is  seen  early ;  if  the  phlyctenulse  are  few  in 
number  and  limited  to  one  portion  of  the  conjunctiva;  if  the  cornea  is 
not  affected,  and  there  is  no  episcleritis.  In  favourable  cases,  the 
disease  generally  runs  its  course  in  from  ten  to  fifteen  days,  and  disap- 
pears without  leaving  any  trace  behind  it.  Very  mild  cases,  in  which 
only  one  or  two  small  phlyctenulte  form  near  the  edge  of  the  cornea 
without  much  irritability  or  vascularity  of  the  eye,  may  even  be  cured 
in  five  or  six  days,  simply  by  a  few  insufflations  of  calomel,  without 
any  other  treatment  whatever.  The  chief  source  of  trouble  and  an- 
noyance is  the  great  tendency  to  relapses.  Perhaps  just  as  the  disease 
seems  to  be  all  but  cui^ed,  fresh  symptoms  of  irritation  supervene,  and 
a  new  crop  of  phlyctenulge  appear.  If  the  disease  then  becomes  compli- 
cated with  episcleritis,  its  course  may  be  very  obstinate  and  protracted. 

Phlyctenular  ophthalmia  occurs  by  far  most  frequently  amongst 
children,  especially  those  of  a  feeble,  scrofulous  habit,  and  of  a  highly 
nervous,  excitable  temperament.  Stellwag  is  of  opinion  that  local 
irritants  acting  upon  the  ciliary  nerves  may  give  rise  to  it ;  as,  for 
instance,  the  premature  and  excessive  use  of  strong  astringent  ooUyria 
in  some  ophthalmige,  whilst  the  irritability  of  the  eye  is  still  very  great. 
The  irritation  may  also  be  propagated  from  other  branches  of  the  fifth 
to  the  ciHary  nerves,  as  in  cases  of  eczema,  impetigo  of  the  cheek,  the 
mucous  membrane  of  the  nose,  etc.  Indeed,  he  thinks  that  the  disease 
is  of  an  herpetic  nature,  and  hence  terms  it  herpes  conjunctiva.  Some 
of  its  varieties  do  not,  however,  bear  any  resemblance  to  herpes  in 
their  course. 

The  treatment  must  be  especially  directed  to  the  following  points  : 
to  diminish  the  irritability  of  the  eye,  to  prevent  any  graver  complica- 
tions, to  hasten  the  absorption  of  the  phlyctenulge,  to  prevent  if  pos- 
sible the  occurrence  of  a  relapse,  and  to  improve  and  strengthen  the 
patient's  general  health. 

If  the  photophobia  is  very  considerable,  a  compress  of  charpie  should 
be  applied  to  the  eye.  This  will  prevent  the  constant  friction  of  the 
lids  against  the  eyeball,  which  greatly  increases  the  irritability,  and 
impedes  the  regeneration  of  the  epithelial  layer  over  the  vesicle  or 
ulcer.  This  point  should  be  more  especially  attended  to  if  the  phlyctenulse 
occur  on  the  cornea,  for  then,  as  we  shall  see  hereafter,  if  their  epithe- 
lial covering  is  shed,  the  denuded  nerve  fibres  of  the  cornea  are  ex- 
posed, and  this  often  gives  rise  to  great  irritability  of  the  eye,  and  the 
most  intense  photophobia,  these  symptoms  often  rapidly  disappearing 
as  soon  as  the  plilyctenuloe  ara  again  covered  by  epitheHum.  In  children 
the  compress  is  especially  useful,  for  it  prevents  their  constantly  rubbing 
the  eyes  with  their  hands,  which  greatly  aggravates  the  irritability. 
Moreover  the  compress  diminishes  the  lachrymation,  soaks  up  the  tears, 


PHLYCTENULAR   OPHTHALMIA.  67 

and  thus  prevents  their  flowing  over  the  cheek,  which  often  gives  rise 
to  excoriations  and  eczema  of  the  lower  eyelid  and  cheek.  The  com- 
press should  be  changed  every  four  or  five  hours,  the  eye  washed  with 
luke-warm  water,  and  the  crusts  removed  from  the  edges  of  the  lids. 
If  the  latter  are  excoriated,  a  little  simple  cerate  or  weak  nitrate  of 
mercury  ointment  should  be  applied  to  them.  The  same  remedies  are  to 
be  applied  to  the  nostrils  if  they  are  excoriated,  or  a  small  dossil  of  lint 
soaked  in  olive  oil  should  be  inserted  into  them.  If  there  is  much  thick 
discharge  from  the  nose,  the  inside  of  the  nostril  should  be  lightly 
touched  with  a  finely  pointed  crayon  of  nitrate  of  silver.  Liebreich* 
strongly  recommends  the  "  Eau  de  Labarraque"  (a  solution  of  soda 
impregnated  with  cldorine  gas)  for  this  purpose.  If  the  lower  lid  and 
cheek  are  much  excoriated  and  eczematous,  a  little  violet  powder  should 
be  dusted  over  the  sores,  or  we  may  use  the  following  powder — 
Zinc.  Oxid.  3j — ij  Pulv.  Amyl.  ^ij.  The  following  lotions  will  also  be 
found  very  serviceable:  —  Plumb.  Acetat.  gr.  x,  Glycer.  5ii — 5SS., 
Aq.  dist.  5vj.,  to  be  applied  tkree  or  four  times  daily.  Instead  of  the 
Acetate  of  lead,  Borax  (5ij)  may  be  employed.  Atropine  drops  must  be 
applied  three  or  four  times  a-day,  but  if  they  are  found  rather  to  increase 
than  allay  the  irritability  of  the  eye,  a  belladonna  collyrium  (Ext.  Bellad. 
5ss  ad  Aq.  dist.  3ij)  must  be  substituted  for  them.  The  compound 
Belladonna  ointment  should  be  rubbed  over  the  corresponding  half  of  the 
forehead  three  or  four  times  daily,  until  a  slight  papular  eruption  is 
produced.  When  the  symptoms  of  irritation  have  subsided,  we  must 
have  recourse  to  the  insufflation  of  calomel,  and  the  application  of  the 
red  precipitate  ointment,  two  remedies  which  may  be  regarded  as  specifics 
for  phlyctenular  ophthalmia.  Indeed  the  calomel  often  acts  as  a  charm,  "/-- 
frequently  causing  a  well-marked  phlyctenula  together  with  the  accom- 
panying vascularity  to  disappear  completely  in  the  course  of  two  or  three 
days.  It  should  not  be  applied  whilst  there  is  much  vascularity,  pho- 
tophobia, or  lachrymation,  as  it  is  apt  to  prove  too  irritating,  but  when 
these  symptoms  have  subsided,  it  should  be  tried  in  very  small  quantity 
at  first,  so  that  we  may  feel  our  way.  Its  beneficial  effect  appears  to  be 
chemical,  and  not  that  of  a  simple  mechanical  irritant,  for  experiments 
made  with  other  finely  powdered  substances  (sugar,  magnesia,  etc.) 
proved  ineffectual.  It  is  supposed  to  act  on  the  Meibomian  glands,  or 
on  the  epitheHal  cells  of  the  conjunctiva.  Bonders  has  found  that  after 
its  use  some  of  the  smaller  conjunctival  vessels  appear  to  become  oblite- 
rated. 

The  calomel  should  be  finely  powdered  and  perfectly  dry,  so  that  it 
does  not  form  clots  on  the  conjunctiva  or  cornea,  for  these  would  act 
as  mechanical  irritants.     It  should   be  applied  with  a  small  camel's 

*  "  Klin.  Mouatsbl.,"  1864,  p.  393. 

F  2 


68  DISEASES   OF   THE   CONJUNCTIVA. 

hair  briisli,  lield  lightly  between  the  forefinger  and  thamb ;  and  a 
slight  quick  fillip  with  the  middle  finger  will  readily  jerk  some  of  the 
powder  into  the  eye.  Care  should  be  taken  not  to  dust  in  too  much, 
more  especially  at  first,  otherwise  it  may  produce  a  good  deal  of  irrita- 
tion. It  should  be  applied  every  day  or  every  other  day,  according  to 
the  requirements  of  the  case,  but  if  the  lids  become  much  gummed 
together  in  the  evening,  it  should  be  applied  less  frequently.  It  is  an 
excellent  remedy  to  prevent  relapses,  and  should,  therefore,  be  continued 
for  eight  or  ten  days  after  the  disease  is  cured.  I  am  in  the  habit  of 
directing  the  patients  to  re-apply  it  at  once,  if  they  experience  any 
renewed  irritation  in  the  eye,  for  its  timely  application  will  generally 
succeed  in  cutting  short  a  renewed  attack  of  the  disease. 

In  childi'en  it  is  often  very  difiicult  to  apply  any  remedy  to  the  eye, 
on  account  of  their  great  restlessness,  or  the  intense  spasm  of  the  eye- 
lids. In  such  cases,  the  head  of  the  patient  should  be  placed  between 
the  knees  of  the  surgeon,  who  is  to  be  seated ;  in  this  way  it  can  be 
firmly  and  steadily  fixed  ;  an  assistant  seated  on  a  chair  opposite 
should  hold  the  child's  arms  and  legs.  The  surgeon  should  then  open 
the  eyelids  with  Desmarres'  broad  silver  elevator,  which  will  enable 
him  to  obtain  a  thorough  view  of  the  eyeball,  and  to  apply  any  remedy. 
By  adopting  this  plan  much  time  and  trouble  will  be  saved,  and  the 
eye  less  irritated  than  by  repeated  ineffectual  attempts  to  examine  it. 

The  red  precipitate  ointment  is  also  an  excellent  remedy.  Although 
it  has  been  long  employed  in  ophthalmic  practice,  we  are  indebted  to 
Pagenstecher  for  the  more  accurate  indications  as  to  its  use,  and  for 
showing  the  advantage  of  employing  it  in  considerably  stronger  doses 
than  was  formerly  done.  He  has  more  lately  substituted  the  yellow 
amorphous  oxide  of  mercury  for  the  red  oxide,  which  is  in  the  finest 
possible  state  of  division,  and,  being  entirely  free  from  any  crystalline 
form,  does  not  adhere  by  any  fine  points  to  the  conjunctiva.*  He  uses 
an  ointment  of  very  considerable  strength,  viz.,  half  a  drachm  or  one 
drachm  of  the  yellow  oxide  of  mercury,  to  an  ounce  of  lard.f  I  have 
generally  found  that  a  much  weaker  ointment  (gr.  x — xxiv  to  the 
ounce)  was  equally  beneficial,  and  caused  less  irritation.  It  should  be 
applied  once  a  day  with  a  small  brush  to  the  inside  of  the  eyelids,  wliich, 
on  being  closed,  will  sweep  ofi"  the  ointment  from  the  brush.  After  a 
few  minutes  it  should  be  wiped  ofi"  from  the  lids  (between  which  it 
becomes  exuded)  with  a  piece  of  fine  linen. 

The  ointment  is  especially  indicated  when  the  symptoms  of  severe 
irritation  have  subsided,  but  it  may  even  be  applied  with  advantage  in 
the    acute  stage,  if  care  be  taken  to  remove  it  completely  from  the 

*  "Nassauer  Corresp.  Bl.,"  No.  10,  1858. 

+  An  interesting  and  valuable  paper,  by  Dr.  Pagensfeclier,  on  the  use  of  this 
ointment  will  be  found  in  the  "  Ophthalmic  Review,"  vol.  ii,  115. 


PHLYCTENULAR  OPHTHALMLV.  69 

conjunctival  sac.     It  is  also  of  great  benefit  in  checking  the  tendency 
to  relapses. 

In  cases  in  which  the  2)hlyctenular  ophthalmia  is  accompanied  by 
much  swelling  of  the  conjunctiva,  and  symptoms  of  catarrhal  con- 
juncti\dtis,  Von  Graefe  has  found  much  benefit  from  chlorine  water, 
as  it  diminishes  the  catari-hal  symptoms,  especially  the  swelling, 
without  setting  up  too  considerable  a  degree  of  irritation,  which  is 
the  chief  danger  in  employing  the  nitrate  of  silver  or  any  strong 
astringents  in  these  cases.  It  is  also  indicated  in  the  prominent  xdcers, 
accompanied  by  episcleritis,  as  it  considerably  hastens  the  formation  of 
the  epithelial  covering  over  the  ulcer.  Some  touch  the  latter  with  the 
point  of  a  crayon  of  nitrate  of  silver,  but  this  is  not  always  free  from 
risk,  especially  when  the  ulcer  is  situated  near  the  cornea,  and  the 
chlorine  water  appears  to  act  more  beneficially. 

It  is  not  advisable  to  apply  blisters  to  the  temple,  as  the  skin  is  often 
extremely  irritable,  and  there  is  frequently  a  great  tendency  to  eczema. 
Great  attention  should  be  paid  to  the  constitutional  treatment  of  the 
patient.  He  should  be  placed  upon  a  nutritious  and  wholesome  diet, 
and  be  allowed  as  much  exercise  in  the  open  air  as  possible.  Cleanli- 
ness should  be  strictly  attended  to,  and  cold  bathing  insisted  upon  if 
the  patient  is  not  too  weak.  Nothing  is  so  injurious  as  to  confine  hina 
in  the  dark  on  account  of  the  photojDhobia,  for  in  this  way  the  eye  will 
become  so  sensitive,  that  no  light  will  be  borne.  Children  are  especially 
prone  to  seek  the  dark,  burying  their  heads  in  their  mother's  lap,  or  in 
a  sofa  or  bed  in  the  corner  of  the  room,  and  only  the  strictest  injunc- 
tions will  make  them  face  the  light.  They  should  be  gradually  accus- 
tomed to  it,  their  eyes  being  perhaps  protected  by  a  shade,  or  a  pair  of 
blue  glasses.  The  compress  bandage  should  only  be  applied  if  the  pho- 
tophobia and  lachrymation  are  very  intense,  and  should  be  left  off  when 
these  symptoms  of  irritation  have  diminished. 

The  use  of  small  doses  of  tartar  emetic  as  a  sedative  is  often  found 
beneficial  more  especially  if  there  is  much  photophobia.  But  care 
should  be  taken  not  to  continue  this  remedy  too  long  so  as  to  debihtate 
and  weaken  the  patient.  The  bowels  should  be  kept  well  regulated, 
and  an  occasional  purge  of  rhubarb  and  jalap,  or  calomel  and  jalap, 
should  be  given,  prrticularly  in  children. 

Tonics,  more  especially  quinine,  are  of  great  benefit.  This  may  be 
given  in  combination  with  steel,  or  also  with  cod  liver  oil.  In  infants 
and  young  children  the  liquor  cinch  onae,  or  the  vinum  ferri  should  be 
administered. 

The  photophobia  often  proves  very  obstinate  and  intractable,  but  as 
a  rule  less  so  than  when  the  cornea  is  also  implicated.  This  spasm  of 
the  lids  (blepharospasm)  is  a  reflex  neurosis,  due  to  an  irritation  of  the 
nerves  of  the  conjunctiva  and  cornea,  which  produces  hypersesthesia  of 


70  DISEASES   OF   THE   CONJUNCTIVA. 

the  orbicularis  muscle  {vide  blepharospasm) .  The  photophobia  dependent 
upon  exposure  of  the  denuded  nerve  fibres  of  the  cornea,  should,  as  has 
been  recommended  above,  be  treated  by  the  application  of  a  compress. 
As  the  health  of  the  patient  improves,  and  he  becomes  more  and  more 
accustomed  to  the  light,  the  photophobia  will  generally  disappear.  In 
children  it  may  be  very  advantageous  to  employ  a  remedy,  which  I  first 
1  saw  very  successful  in  Von  Graefe's  hand,  viz.,  the  dipping  their  heads 

/2  0   ^        I  lender  water,  as  this  breaks  the  ^ircuit  of  reflex  action  by  the  intense 
^X'         I  fright  of  the  child.     This   should,   if  necessary,  be  repeated  several 

,  ^ ..-  '    times,  even  at   one   sitting,  until  the  child  opens  its  eyes  properly.     I 

have  often  seen  surprising  results  from  this  treatment,  when  all  other 
remedies  had  failed.  The  head  must,  however,  be  well  dipped  under 
water,  so  that  mouth,  nose,  and  eyes  are  immersed,  the  child  being 
kept  in  this  position  for  a  few  seconds,  which  will  effectually  frighten  it. 
I  have  also  obtained  muqli  benefit  in  severe  blepharospasm  from  the 
subcutaneous  injection  of  morphia  in  the  region  of  the  supra-orbital 
nerve.  The  division  of  this  nerve  will  not  be  necessary  in  the  photo- 
phobia accompanying  phlyctenular  ophthalmia. 

9.— EXAN"THEMATOUS  OPHTHALMIA. 

The  eyes  often  become  affected  in  measles  and  scarlatina.  In  the 
milder  cases  the  conjunctiva  becomes  hyperasmic,  and  perhaps  symp- 
toms of  catarrhal  conjunctivitis  supervene.  Esiceptionally,  however, 
the  inflammation  may  assume  a  more  severe  muco-purulent  charac- 
ter, leading  perhaps  to  perforating  ulcers  of  the  cornea,  prolapse 
of  the  iris  and  anterior  staphlyloma ;  this  is  more  especially  liable  to 
occur  in  children  of  a  weakly  scrofulous  diathesis.  Not  unfrequently 
the  conjixnctivitis  presents  the  phlyctenular  form,  being  accompanied 
by  much  photophobia,  lachrymation,  and  general  irritability  of  the  eye. 
Extensive  ulcers  of  the  cornea  or  iritis  are  only  of  rare  occurrence. 

In  the  majority  of  cases  the  treatment  need  only  be  very  simple. 
The  eyes  should  be  guarded  against  the  Hght,  be  frequently  washed, 
so  that  any  discharge  may  be  cleansed  away,  and  if  there  is  much 
hypergemia,  or  any  inflammation  of  the  conjunctiva,  or  catarrhal  oph- 
thalmia, a  mild  astringent  collyrium,  of  zinc,  acetate  of  lead,  or  alum 
should  be  prescribed.  If  there  is  much  photophobia  and  lachrymation 
together  with  phlyctenulfe  on  the  conjunctiva  or  cornea,  atropine  or 
belladonna  drops  should  be  applied  to  the  eye,  and  the  compound  bella- 
donna ointment  be  rubbed  in  over  the  forehead.  The  s-eneral  health 
should  at  the  same  time  be  attended  to. 

In  small  pox  the  eyes  are  apt  to  suffer  in  a  far  more  dangerous 
manner,  for  the  inflammation  is  not  only  more  severe,  but  the  variolous 
pustules  may    form  on    the  lids,   the  conjunctiva,    and   even    on    the 


EXAXTHEMATOUS   OPHTHAL.Mi.E.  71 

cornea,  leading  to  gi'av&,  and  often  very  dangerous  complications. 
Happily,  since  the  introduction  of  vaccination,  the  variolous  ophthalmia 
is  far  less  dangerous  than  formerly,  when  it  led  but  too  frequently  to 
destruction  of  the  sight. 

If  a  considerable  number  of  pustules  form  on  the  eyelids,  the 
swelling  of  the  latter  is  often  so  great  that  it  is  impossible  to  open  the 
eye.  They  are  also  apt  to  form  at  the  very  edge  of  the  lid  between  the 
eyelashes,  and  often  destroy  the  hair  bulbs,  thus  producing  perhaps 
permanent  loss  of  the  eyelashes  (madarosis).  If  they  are  situated  on 
the  palpebral  conjunctiva  near  the  edge  of  the  eyelid,  they  may  oblite- 
rate the  openings  of  the  Meibomian  glands,  and  cause  a  stoppage  and 
alteration  in  their  secretions ;  or  the  growth  and  arrangement  of  the 
lashes  may  become  affected,  and  distichiasis  or  trichiasis  be  pro- 
duced. If  the  pustules  form  on  the  limbus  conj unctivee,  they  are 
chiefly  dangerous  inasmuch  as  they  may  extend  to  the  cornea.  The 
very  prevalent  opinion  that  variolous  pustules  often  form  on  the  con- 
junctiva and  the  cornea,  during  the  eruptive  stage,  has  been  distinctly 
denied  by  Drs.  Gregory  and  Marson.  The  latter  es|iecially  main- 
tains most  strongly  that  no  pustules  form  on  the  eye.  The  conjunc- 
tival inflammation  met  with  in  small  pox  may  assume  the  catarrhal, 
muco-purulent,  or  phlyctenular  character.  The  latter  is  perhaps  the 
most  common.  The  eyelids  and  lachrymal  apparatus  are  often  affected, 
and  this  frequently  gives  I'ise  to  very  obstinate  and  troublesome  com- 
plications. 

But  the  eye  may  become  affected  at  a  later  stage  of  the  disease, 
when  the  scales  have  fallen  off*  from  the  pustules.  Hence  this  has 
been  termed  by  some  writers,  "secondary  variolous  ophthalmia." 
Mackenzie  mentions  that  he  has  often  seen  both  central  abscess  of  the 
cornea  and  onyx  at  its  lower  edge  produced,  after  the  general  eruption 
has  completely  gone.  Although  this  generally  occurs  about  the  12th 
day,  he  states  that  it  may  even  take  place  five  or  six  weeks  after  the 
patient  has  recovered  from  the  primary  disease.  At  first  an  infiltra- 
tion of  the  cornea  occurs,  which  generally  soon  passes  over  into  an 
ulcer,  and  which,  increasing  in  circumference  and  depth,  may  per- 
forate the  cornea,  producing  prolapse  of  the  iris  or  partial  staphyloma. 
If  several  of  such  infiltrations  should  coalesce,  a  large  ulcer  or  abscess 
will  be  formed,  giving  rise  to  an  extensive  leucoma,  even  if  the  cornea 
do  not  perforate.  Should  the  whole  cornea  be  destroyed  by  suppura- 
tion, a  complete  staphyloma  w411  be  the  result.  Again,  the  inflamma- 
tion may  attack  the  other  structures  of  the  eye,  and  the  latter  be  lost 
from  panojihthalmitis. 

The  treatment  should  be  much  the  same  as  that  recommended  for 
the  ophthalmia  of  measles  and  scarlatina.  In  order  to  prevent  the 
formation  of  pustules  on  the  eyelids,  glycerine,  olive  oil,  or  unscented  cold 


72  DISEASES   OF   THE   CONJUNCTIVA. 

cream  should  be  freely  rubbed  over  tliem  three  or  four  times  daily. 
Mackenzie  recomm.ends  that  two  or  three  leeches  should  be  applied 
to  the  temples,  or  behind  the  ears.  In  the  secondary  variolous  ophthal- 
mia, he  has  found  much  benefit  from  tartar  emetic,  given  so  as  to 
cause  free  vomiting  and  pui'ging.  The  general  health  should  be  kept 
up  by  tonics,  and  the  bowels  properly  attended  to.  If  pustules  form 
on  the  lids  or  conjunctiva,  they  should  be  pricked  and  emptied  of  their 
contents.  If  the  cornea  becomes  implicated,  and  perforation  is  threat- 
ened, this  must  be  treated  according  to  the  rules  laid  down  in  the 
treatment  of  ulcers  of  the  cornea. 

In  erysijDelas  of  the  face,  the  conjunctiva  is  often  afiected,  and  this 
is  accompanied  by  very  great  swelling  of  the  eyelids.  The  cornea 
becomes  but  seldom  implicated. 

10.— XEROPHTHALMIA. 

In  this  condition,  the  conjunctiva  is  thickened,  dry,  and  of  a 
dusky  red  colour,  its  epithelial  surface  being  rough  and  scaly.  If 
the  afiection  exists  to  a  considerable  extent,  both  the  palpebral  and 
ocular  conjunctiva  assume  a  dirty,  greyish-white  appearance,  and 
become  rough,  dry,  and  cuticular.  This  condition  is  due  to  atrophy 
of  the  conjunctiva,  subconjunctival  tissue,  and  even  of  the  cartilage,  all 
of  Avhich  undergo  cicatricial  changes,  the  nature  of  which  has  been 
already  mentioned  under  the  head  of  granular  ophthalmia.  The 
secreting  apparatus  of  the  conjimctiva  is  more  or  less  destroyed,  and 
this  membrane  assumes  more  the  character  of  the  cutis.  On  account 
of  this  disturbance  in  the  secretions  of  the  eye,  the  latter  appears  dry, 
and  the  patient  experiences  a  most  annoying  sensation  of  heat,  dryness, 
and  stiffness  in  the  eyes.  The  puncta  are  generally  much  contracted, 
or  even  obliterated.  The  semilunar  fold  is  also  hardly  apparent. 
There  is,  moreover,  always  more  or  less  posterior  symblepharon,  so 
that  the  hollow  in  the  retro-tarsal  region  is  obliterated,  and  the 
palpebral  conjunctiva  passes  abruptly  on  to  the  eyeball.  Sometimes 
small  fraena  exist  between  the  lid  and  the  globe.  During  the  move- 
ments of  the  eye  the  ocular  conjunctiva  is  thrown  into  small  concentric 
folds  round  the  cornea.  The  latter  is  generally  opaque,  often  very 
considerably  so,  the  opacity  assuming  perhaps  the  character  of  pannus, 
and  extending  over  the  greater  portion,  or  even  the  whole  of  the 
cornea.  The  surface  of  the  cornea  is  generally  rough  and  uneven,  and 
its  sensibility,  as  well  as  that  of  the  conjunctiva,  is  greatly  impaired, 
so  that  mechanical  irritants,  dust,  dirt,  foreign  bodies,  etc.,  are  hardly 
felt,  and  excite  little  or  no  u'ritation. 

Xerophthalmia  is  generally  caused  by  long  continued  and  severe 
inflammation  of  the  conjunctiva,  more  especially  by  the  chronic  diffuse, 


PTERYGIUM.  73 

granular  ophthalmia,  which  is  so  apt  to  give  rise  to  extensive  atrophy 
and  cicatrices  of  the  conjunctiva,  and  tarsal  cartilage.  It  may  also 
arise  after  diphtheritic  conjunctivitis,  or  be  produced  by  injuries  to  the 
conjunctiva,  from  strong  acids,  lime,  &c.,  and  the  excessive  and  long 
continued  use  of  strong  caustics,  more  especially  the  nitrate  of  silver. 
In  the  latter  case,  we  find  not  only  that  the  palpebral  and  ocular  con- 
junctiva have  become  dry  and  cuticular,  but  that  they  are  very  markedly 
discoloured,  being  of  a  dirty,  olive-green  tint,  which  is  extremely 
unsightly. 

Unhappily  no  treatment  is  of  much  avail.  We  can  only  endeavour  to 
remedy  the  dryness  of  the  eye,  due  to  the  absence  of  its  normal  secre- 
tions, by  the  frequent  use  of  some  bland  fluid  employed  as  a  collyrium. 
I  have  found  milk  answer  far  better  than  any  other,  which  has  been 
also  strongly  recommended  by  Von  Graefe.  Benefit  is  also  sometimes 
experienced  from  the  use  of  glycerine,  which  was  first  proposed  by 
Mr.  Taylor.  The  effect  of  these  apjjlications  is  to  soften  and  wash  away 
the  hardened  epithelial  scales,  and  sometimes  perceptibly  to  clear  the 
opacity  of  the  cornea. 

11.— PTERYGIUM. 

This  affection  is  due  to  an  hypertrophy  of  the  conjunctival  and 
subconjunctival  tissue,   showing  here  and  there  tendinous  or  fibrillar 
expansions.      The  elevated  portion  of  the  conjunctiva  is  traversed  by 
numerous  blood-vessels,  which  run  a  horizontal  course.     If  the  vascu- 
larity is  but  slight,  and  the  hypertrophy  of  the  tissue  but  inconsiderable, 
it  is  termed  j3^er^(/r?t  Hi-  tenue,  whereas,  if  the  thickening  is  extensive  and 
the  development  of  blood-vessels  great,   so  that  it  looks  like  a  well- 
marked   red   elevation — somewhat  resembling   a  muscle — it  is  called 
ptenjffkim  crassum.     It  is  always  triangular  or  fan-like  in  shape,  having 
its  base,  which  is  often  very  wide,  turned  towards  the  semi-lunar  or 
retro-tarsal  fold,  and  its  apex  towards  the  cornea.     It  sometimes  passes 
close  up  to  the  edge  of  the  latter  and  stops  short  just  at  the  limbus 
conjunctivae ;  in  other  cases  it  passes  beyond  this,  and  extends  more  or 
less  on  to  the  coi"nea,  even  reaching  perhaps   to  the   centre,  but  very 
seldom  extending  beyond  the  latter.     Its  apex  is  generally  not  very 
acute  or  pointed,  but  rather  rounded  ofi"  or  indented.       The  portion 
situated  on  the  cornea  looks  tendinous  rather  than  vascular,  or  is  made 
up  of  loose  connective  tissue  like  that  on  the  sclerotic.     It  may  be  so 
superficial  as  to  be  readily  shaved  oS",  or  it  may  extend  deeper  into  the 
substance  of  the  cornea,  so  that  when  it  is  removed  an  irregular  hollow 
or  furrow  is  left  behind.     The  pterygium  is  mostly  but  loosely  con- 
nected with  the  sclerotic  and  cornea,  and  with  a  pair  of  forceps  it  can 
readily  be  lifted  up  in  a  fold.     But  if  the  tendinous  bands  in  its  con- 


74  DISEASES   OF   THE   CONJUNCTIVA. 

junctival  portion  are  considerable  and  dense,  this  laxity  is  a  good  deal 
impaired  and  the  elevation  is  rather  tense  and  stretched,  thus  impeding 
the  movements  of  the  eyeball  to  a  certain  extent,  which  gives  rise  to  a 
sensation  of  tightness  or  dragging  when  the  eye  is  moved.  The 
pterygium  is  most  frequently  met  with  at  the  inner  angle  of  the  eye, 
corresponding  to  the  situation  of  the  internal  rectus  muscle.  It  is 
occasionally  symmetrical  in  the  two  eyes.  It  is  less  frequently  seen  at 
the  outer  angle,  and  still  less  upwards  or  do^vnwards.  In  some  rare 
cases  two  or  even  more  have  occurred  on  the  same  eye.  It  occurs  in 
adults,  but  is  most  frequently  seen  in  persons  beyond  middle  age,  and 
very  rarely  in  children. 

The  causes  of  pterygium  are  often  somewhat  obscure  and  uncertain, 
as  its  formation  is  generally  very  slow  and  gradual.  There  can  be  no 
doubt  that  long  and  constant  exposure  to  heat,  glare,  wind,  dust,  and 
chemical  irritants  may  produce  it,  by  setting  up  a  state  of  chronic 
irritation  of  the  conjunctiva,  which  gradually  leads  to  a  thickening  and 
hypertrophy  of  this  membrane  and  the  subconjunctival  tissue.  This 
occurs  particularly  in  situations  which  are  specially  exposed  to  these 
influences,  namely,  at  the  inner  and  outer  angle  of  the  cornea,  which 
lie  in  the  palpebral  aperture,  and  are  unprotected  by  the  lids.  I  have 
frequently  met  with  this  affection  in  persons  who  have  long  resided  iu 
hot  climates,  especially  in  several  natives  of  the  West  Indies,  and  this 
agrees  vdth  the  experience  of  other  observers.  Pterygium  may  also  be 
produced  by  phlyctenular  and  even  catarrhal  ophthalmia. 

Arlt*  has,  I  think,  offered  by  far  the  most  reasonable  and  probable 
explanation  of  the  formation  of  pterygium  in  many  cases.  He  thinks 
that  it  is  frequently  produced  in  the  following  manner  : — If  a  superficial 
ulcer  or  abrasion  (due  perhaps  to  some  chemical  or  mechanical  injury) 
exists  at  the  very  edge  of  the  cornea,  the  conjunctiva  near  it,  particu- 
larly if  it  be  somewhat  excoriated  and  relaxed,  as  is  often  the  case  in 
old  people,  falls  against  it,  and  becomes  adherent  to  the  ulcer,  being  at 
the  same  time  dragged  somewhat  towards  it.  This  is  always  accom- 
panied by  a  certain  degree  of  irritation  and  serous  infiltration  of  the  con- 
junctiva, which,  on  the  serum  becoming  absorbed,  causes  a  certain  amount 
of  contraction  and  dragging  of  the  membrane.  Shoald  the  external  irri- 
tants continue  to  act  upon  the  eye,  we  can  easily  understand  how  this 
condition  is  not  only  maintained  but  increased  in  extent,  the  conjunctiva 
being  gradually  more  and  more  dragged  upon  and  involved  in  the 
process.  Hasnerf  has  more  lately  pointed  out  that  the  connection 
between  the  conjunctiva  and  subconjunctival  tissue  at  the  limbus  con- 
iunctivaj  is  often  relaxed,  more  especially  in  aged  persons,  and  that  this 

*"  Diseases  of  the  Eye."     1855. 

t  "  Clinical  Observations,"  Prague,  1865. 


PTERYGIUM.  75 

forms  a  frequent  predisposing  cause  of  pterygium.  A  simple  hypertrophy 
of  the  tissue  may  then  suffice  to  draw  up  the  neighbouring  conjunctiva, 
but  this  will,  of  course,  be  much  more  likely  to  occur  if  an  ulcer  or 
excoriation  is  formed,  for  during  the  cicatrization  the  conjunctiva  will 
be  more  or  less  dragged  upon. 

The  pterygium  is  often  but  of  slight  extent  and  may  increase  but 
very  slowly,  remaining  indeed  almost  stationary  for  a  length  of  time, 
and  without  perhaps  encroaching  upon  the  cornea.  In  other  cases  its 
course  is  more  rapid,  and  it  may  extend  quite  to  the  centre  of  the 
cornea,  thus  more  or  less  affecting  the  sight  and  impairing  the  move- 
ments of  the  eye.  Even  if  the  pterygium  is  in  such  cases  removed  some 
opacity  of  the  cornea  ay  ill  remain,  so  that  it  may  be  necessary  to  make 
an  artificial  pupil. 

If  the  pterygium  is  but  small,  and  is  chiefly  confined  to  the  sclerotic, 
benefit  is  often  derived  from  the  application  of  astringent  collyria,  such 
as  the  sulphate  of  copper  or  zinc,  the  vinum  opii,  or  even  the  nitrate 
of  silver,  more  especially  if  there  is  any  catarrhal  ophthalmia.  The 
application  of  the  powdered  acetate  of  lead  (as  recommended  in  granular 
ophthalmia)  has  also  been  advocated  (Deconde).  But  if  the  disease 
is  considerable,  so  that  it  annoys  the  patient  during  the  movements  of 
the  eye,  or  if  from  its  position  on  the  cornea  the  sight  is  affected,  these 
remedies  will  not  suffice,  and  we  must  have  recourse  to  operative  treat- 
jnent.  Unfortunately  this  is  not  always  so  successful  as  we  could 
desire,  for  if  the  pterygium  encroaches  much  on  the  cornea,  an  exten- 
sive opacity  will  be  left ;  and  if  the  base  of  the  pterygium  is  large  the 
loss  of  substance  will  be  considerable,  and  the  resulting  cicatrix  will  be 
dense,  tendinous,  and  more  or  less  prominent,  giving  rise  to  what  has 
been  termed  "secondary  pterygium,"  which  may  even  necessitate  a 
further  operation.  This  is  especially  apt  to  occur  if  excision  has  been 
performed,  and  the  wound  has  been  made  triangular  in  shape. 

Numerous  modes  of  operating  for  pterygium  have  been  advocated, 
but  I  shall  confine  myself  to  the  description  of  the  three  following,  viz. : 
1,  Excision;  2,  Transplantation;  3,  Ligature.  Of  these  I  have  found 
the  transplantation  the  most  successful. 

1.  Excision. — This  operation  is  to  be  performed  in  the  following- 
manner  : — The  patient  having  been  placed  under  the  influence  of  chloro- 
form, and  the  eyelids  kept  apart  by  the  spring  speculum,  the  operator 
seizes  the  pterygium  with  a  pair  of  finely-toothed  forceps,  and  raising  it 
up,  carefully  abscises  the  corneal  portion  either  with  a  cataract  knife  or  a 
pair  of  curved  scissors.  When  the  pterygium  has  been  removed  from 
the  comea,  its  conjunctival  portion  is  to  be  excised  up  to  about  l-^-  or  2 
lines  from  the  edge  of  the  cornea.  The  lines  of  incision  should  run 
along  the  upper  and  lower  edge  of  the  pterygium  for  the  desired 
extent,  and  should  then  be  made  to  converge  towards  each  other,   so 


76  DISEASES   OF   THE   CONJUNCTIVA. 

that  the  wound  may  not  assume  a  triangular  but  a  rhomboidal  shape. 
The  hypertrophied  tissue  having  been  thoroughly  removed,  the  edges 
of  the  conjunctival  wound  are  to  be  accurately  brought  together  by 
two  or  three  fine  sutures.  As  the  edges  of  the  incision  are  apt  to  be 
somewhat  uneven  and  ragged  from  the  irregular  dragging  of  the  con- 
junctiva into  the  pterygium,  I  have  found  it  advantageous  to  pass  the 
threads  through  the  conjunctiva  prior  to  the  excision,  so  as  to  embrace 
the  pterygium  to  the  desired  extent,  and  then  to  make  the  incisions 
within  the  line  of  the  sutures,  which  will  be  a  guide  to  the  operator 
and  enable  hira  to  render  them  more  straight  and  even.  The  suggestion 
of  making  the  wound  rhomboidal  instead  of  triangular  is  due  to  Arlt. 
The  chief  advantage  of  this  is,  that  its  edges  can  thus  be  made  to  fit 
more  neatly  and  closely  together,  that  it  yields  a  more  even  and  straighter 
line  of  adhesion,  and  that  the  tendency  to  the  formation  of  a  thick, 
prominent  cicatrix  is  thus  greatly  diminished.  Whereas,  if  the  wound  is 
made  triangular,  the  angles  of  the  base  of  the  triangle  become  puckered 
and  projecting  when  the  edges  are  united  by  sutures,  and  the  central 
portion  of  the  base  is  apt  to  be  drawn  towards  the  cornea,  thus  in- 
creasing the  tendency  to  a  prominent  cicatrix. 

It  is  not  necessary,  nor  indeed  desirable,  to  remove  the  pterygium 
as  far  the  semilunar  or  retro-tarsal  fold,  the  extent  mentioned  above 
will  generally  suffice.  Pagenstecher*  does  not  excise  the  pterygium, 
but  having  separated  it  from  the  cornea  and  the  sclerotic  to  the 
required  extent,  he  simply  turns  it  back,  and  brings  the  edges  of  the 
wound  together  by  siitures.  The  pterygium  soon  shrinks,  dwindles 
down,  and  gradually  disappears  altogether. 

2.  Transplantation,  which  is  chiefly  apphcable  when  the  pterygium  is 
very  large,  was  first  introduced  by  Desmarres.f  He  abscises  the  pterygium 
from  the  cornea  and  sclerotic  quite  up  to  the  base,  and  then  turns  it  back 
towards  the  nose.  He  next  makes  an  incision  in  the  conjunctiva  near 
and  parallel  to  the  lower  edge  of  the  cornea,  and  sufficiently  large  to 
receive  the  pterygium  ;  the  latter  is  then  inserted  into  this  incision  and 
retained  in  this  position  by  a  few  sutures. 

The  chief  advantages  of  this  proceeding  are,  that  the  conjunctiva  is 
preserved,  that  the  pterygium  soon  shrinks  in  its  new  situation,  and 
that  there  is  far  less  chance  of  recurrence  than  when  excision  is 
practised. 

3.  The  ingenious  operation  by  ligature  was  suggested  by  Szokalski.  J 
A  couple  of  small  curved  needles  having  been  armed  with  the  ends  of 
a  fine  silk  thread,  the  operator,  lifting  up  the  pterygium  with  a  pair 

*  "  Klinisclie  Beobachtuugen,"  1861. 

t  "  Maladies  des  Yeux,"  2. 

X  "Arch.  f.  Physiol-Heilkunde,"  1815,  2. 


SYMBLEPHARON. 


77 


of  forceps,  inserts  one  needle  at  its  upper  edge,  near  the  cornea,  and 
passing  it  beneath  the  pterygium,  brings  it  out  at  the  lower  edge 
(Fig.  6).     The  other  needle  is 

then  passed  in  the  same  manner  ^^' 

beneath  the  pterygium,  near  its 
base.  The  needles  are  then  cut 
off,  and  the  ligature  will  con- 
sequently be  divided  into  three 
portions,  viz.,  an  outer,  an  inner, 
and  a  central  one.  The  ends  of 
the  outer  thread  are  then  to  be 
firmly  tied,  so  as  to  tightly 
embrace  this  portion  of  the 
pterygium,  then  the  ends  of  the 
outer  thread  are  to  be  united, 
and,  fi.nally,  the  two  ends  of  the 
central  ligature,  which  lie  at  the 
lower  edge  of  the  pterygium, 
are  to  be  firmly  tied.  The  ends 
of  the  ligatures  may  be  snipped 

off,  or  fastened  to  the  cheek  by  strips  of  adhesive  plaster.  At  the  end 
of  four  days,  the  strangulated  portion  of  the  pterygium  may  generally 
be  easily  removed  with  a  pair  of  forceps.  The  affection  is  said  never 
to  recur  after  this  operation. 

We  must  not  confound  a  little  yellow  spot  near  the  cornea  (pingue- 
cula  or  pterygium  pingue)  with  true  pterygium.  It  often  appears  on 
the  conjunctiva  of  elderly  persons,  near  the  edge  of  the  cornea,  in  the 
form  of  a  small  yellow  elevation.  It  is  not  of  a  fatty  nature,  but  is 
due  to  an  hypertrophy  of  the  subconjunctival  tissue,  accompanied  by 
thickening  of  the  epithelium  (Weller),  It  but  seldom  causes  any 
inconvenience ;  should  it  do  so,  it  may  be  snipped  off  with  a  pair  of 
scissors. 


Aftei-  Stellwag  de  Carion. 


12.— SYMBLEPHARON. 


In  this  affection  there  exists  an  adhesion  between  the  conjunc- 
tiva of  the  eyelid  and  that  of  the  eyeball.  This  frrenum  may  be 
extensive,  and  nearly  the  whole  length  of  the  palpebral  conjunctiva 
(of  one  or  both  lids)  be  adlierent  to  the  opposite  surface  of  the 
globe,  prodiicing  a  considerable  limitation  of  the  movements  of  the 
eyeball ;  or,  the  adhesion  may  be  very  limited,  so  that  only  a  narrow 
bridle  exists.  In  the  latter  case,  there  may  be  simply  a  small 
bridge  of  conjunctiva   passing   from   the   lid  to  the  eyeball,  readily 


78  DISEASES   OF   THE   CONJUNCTIVA. 

permitting  the  passage  of  a  probe  beneath  it ;  or,  the  adhesion 
may  include  a  portion  of  the  retro-tarsal  fold,  in  which  case  no 
passage  would  exist.  In  some  cases  we  have  a  combination  of  the 
two,  the  probe  passing  only  part  of  the  way.  If  the  palpebral  con- 
junctiva adheres  to  the  cornea,  it  has  been  termed  "  symblejiharon  cum 
cornea,"  and  it  then  assumes  somewhat  the  character  and  appearance 
of  a  pterygium.  The  most  frequent  causes-  of  symblepharon  are 
injuries  from  red  hot  metal,  molten  lead,  gunpowder  exploding  near 
the  eyes,  strong  acids,  or  quicklime.  These  produce  more  or  less 
extensive  sloughing  and  excoriation  of  the  conjunctiva  of  the  lid  and 
eyeball,  granulations  form,  and  the  opposite  excoriated  surfaces  become 
firmly  united.  If  these  adhesions  are  but  of  limited  extent,  the  con- 
stant movements  of  the  eyeball  will  gradually  stretch  them,  until  the 
frsena  become  perhaps  considerably  elongated.  Wounds  penetrating 
through  the  eyelids  into  the  globe  may  also  produce  symblepharon. 
It  is  but  seldom  due  to  ulcerations  or  pustules  accompanying  in- 
flammiation  of  the  conjunctiva. 

The  effect  which  an  operation  will  have  in  the  cure  of  a  sym- 
blepharon, will  depend  chiefly  upon  the  extent  of  the  latter.  If 
it  is  very  considerable,  embracing  the  retro-tarsal  fold,  and  pro- 
ducing a  close  adhesion  between  the  lid  and  the  eyeball,  generally 
but  little  good  can  be  done  by  an  operation.  The  most  favour- 
able cases  are  those  in  which  a  narrow  band  passes  like  a  bindge 
from  the  palpebral  to  the  ocular  conjunctiva,  so  that  a  probe  can 
be  freely  inserted  beneath  it.  But  even  those  cases  in  which 
the  adhesion  passes  to  the  retro-tarsal  fold  may  sometimes  be 
much  improved  if  the  fraenum  is  but  small.  If  one  or  two 
narrow  membranous  bands  exist,  they  shovild  be  put  on  the  stretch 
and  divided  close  to  the  globe,  and  re-union  should,  if  possible,  be 
prevented  by  frequently  jDassing  a  probe  dipped  in  a  little  oil  or 
glycerine  between  the  raw  surfaces ;  or,  these  may  be  touched 
lightly  with  a  crayon  of  nitrate  of  silver,  in  order  that  an  eschar 
may   be   formed,    and   adhesion   prevented. 

When  the  adhesion  is  more  extensive,  a  simple  division  of  the 
frsenum  will  not  suffice,  for  the  raw  surfaces  will  be  so  consider- 
able in  size,  that  they  are  sure  to  re-unite,  for,  as  they  contract 
during  granulation,  the  opposing  surfaces  will  be  again  drawn  towards 
each  other.  Many  of  these  cases  appear  to  do  very  well  at  first,  but, 
after  a  time,  a  relapse  generally  occurs,  so  that  finally  they  are  hardly, 
if  at  all,  improved  by  the  operation.  In  order  to  prevent  this  re-union 
of  the  raw  surfaces,  it  has  long  been  proposed  to  interpose  a  small 
shield  of  glass,  horn,  or  ivory  between  the  lid  and  eyeball.  This  has 
often  been  tried,  but  has  almost  always  failed,  except  where  the  frrena 
are  very  narrow,  for  as  the  wound  cicatrizes  the  parts  in  its  vicinity 


SYMBLEPHAROy. 


79 


contract,  and  tlius  gradually  push  out  the  shield.  Mr.  Wordsworth* 
uses  a  glass  mask,  instead  of  a  metal  shield.  It  is  a  glass  shell,  like  an 
artificial  eye,  having  a  central  aperture  for  the  cornea.  He  has  found 
it  very  successful  in  the  treatment  of  extensive  fr^na,  and  in  cases  of 
destruction  of  the  epithelium  of  the  conjunctiva,  in  which  symblepharon 
was  imminent. 

In  order  to  obviate  this  tendency  to  re-union,  Arlt  has  introduced 
and  practised  Avith  success  the  following  operation. f  The  eyelid  having 
been  drawn  away  from  the  globe,  so  as  to  put  the  fra3num  well  on  the 
stretch,  the  operator  passes  a  curved  needle,  armed  with  a  fine  silk 
thread,  through  the  symblepharon,  close  to  the  cornea,  the  adhesion  is 
then  to  be  carefully  dissected  off  from  the  cornea  and  sclerotic  as  far  as 
the  retro-tarsal  fold.  Two  curved  needles  having  been  armed  with  the 
thread,  the  symblepharon  is  doubled  down,  so  as  to  bring  its  conjunc- 
tival surface  in  contact  with  the  raw  surface  of  the  globe,  and  the 
needles  are  then  passed  through  the  thickness  of  the  lid,  close  to  the 
orbital  edge,  and  the  sutures  tied  on  the  outside  of  the  lid,  so  as  to 
keep  the  sjTnblepharon  folded  down  in  the  required  position.  If  the 
fraenum  is  not  very  broad,  the  edges  of  the  wound  in  the  ocular  con- 
junctiva should  be  brought  together  by  two  or  three  fine  sutures. 
After  the  operation,  cold  compresses  are  to  be  applied.  When  the 
conjunctival  wound  is  healed,  the  turned  down  symblepharon,  which 
will  by  this  time  have  shrunk  considerably,  may  be  excised  if  it  should 
prove  ii'ksome  to  the  patient. 

The  operation  which  I  have  found  most  successful  for  the  perma- 
nent cure  of  moderate  cases  of  symblepharon,  is  that  of  transplantation, 
for  which  we  are  indebted  to  Mr.  Teale.J  He  describes  the  mode  of 
operating,  as  follows  : — 

"  Having  first  made  an  incision  through  the  adherent  lid,  in  a 
line  corresponding  to  the  margin  of  the  concealed  cornea  (see  A,  Fig.  7), 
I  dissected  the  lid  from  the  eyeball,  until  the  globe  moved  as  freely  as  if 


Fig.  7. 


*  "Eoy.  Lond.  Ophtlial.  Hosp.  Reports,"  vol.  iii,  216. 

+  "  Prager  Vierteljalirschrift,"  xi,  161. 

:}:  "  Roy.  Lond.  Ophthal.  Hosp.  Reports,"  iii,  253. 


80  DISEASES   OF   THE   CONJUNCTIVA. 

there  had  been  no  unnatural  adhesions.  Thus,  the  apex  of  the  sjmble- 
pharon  (A,  Fig.  8)  being  part  of  the  skin  of  the  lid,  was  left  adherent 
to  the  cornea. 

"  In  the  next  place,  two  flaps  of  conjunctiva  were  formed,  one 
from  the  surface  of  the  globe,  near  the  inner  extremity  of  the  raw  sur- 
face, the  other  from  the  surface  of  the  globe,  near  the  outer  extremity. 
I  first  marked  out,  with  a  Beer's  knife,  a  flap  of  conjunctiva  (B,  Fig.  8) 
nearly  a  quarter  of  an  inch  in  breadth,  and  two  thirds  of  an  inch  in 
length,  with  its  base  at  the  sound  conjunctiva,  bounding  the  inner 
extremity  of  the  exposed  raw  surface,  and  its  apex  passing  towards  the 
upper  surface  of  the  eyeball.  The  flap  was  then  carefully  dissected 
from  the  globe,  until  it  was  so  far  at  liberty  as  to  stretch  across  the 
chasm  without  great  tension,  care  being  taken  to  leave  a  sufiicient 
thickness  of  tissue  near  its  base.  A  second  flap  was  then  made  on  the 
outside  of  the  eyeball  in  the  same  manner.  In  making  the  flaps,  con- 
junctiva alone  was  taken,  the  subconjunctival  tissue  not  being  included. 
The  two  flaps  thus  made  were  then  adjusted  in  their  new  situation 

(see   Fig.   9).      The  inner  flap,   B,   was 
made  to  stretch  across  the  raw  sui'face 


of  the  eyelid,  being  fixed  by  its  apex 
to  the  healthy  conjunctiva,  at  the  outer 
edge  of  the  wound.  The  outer  flap,  C, 
was  fixed  across  the  raw  surface  of  the 
eyeball,  its  apex  being  stitched  to  the 
conjunctiva  near  the  base  of  the  inner 
flap.  Thus,  the  two  flaps  were  dovetailed 
into  the  wound.  The  flaps  having  been  adjusted  in  their  new  position, 
their  vitality  was  further  provided  for  by  incising  the  conjunctiva  near 
theii'  base,  in  any  direction  in  which  thei-e  seemed  to  be  undue  tension, 
and  by  stitching  together  the  margins  of  the  gap  whence  the  transplanted 
conjunctiva  had  been  taken  (e.g.  D,  E,  Fig.  9).  One  or  two  other 
sutures  were  inserted,  with  a  view  to  prevent  doubling  in  of  the  edges 
of  the  transplanted  conjunctiva."  The  apex  of  skin  left  on  the  cornea 
soon  atrophies  and  disappeai's. 


13.— ANCHYLOBLEPHAROK 

By  this  is  meant  a  more  or  less  extensive  thin,  membranous  or 
cicatricial  adhesion  of  the  edges  of  the  eyelids  to  each  other.  It 
frequently  co-exists  with  symblepharon,  the  same  injury  having  given 
rise  to  both  these  conditions.  Sometimes  the  adhesion  is  confined  to 
the  inner  angle  of  the  eye,  leaving  perhaps  a  small  opening  through 
which  the  tears  can  escape  and  a  probe  may  be  passed.     Extensive 


INJURIES  OF   THE  CONJUNCTIVA.  81 

membranous  adhesions  between  the  edges  of  the  Hd  are  generally  con- 
genital. The  most  frequent  causes  of  anchyloblepharon  are  chemical 
and  mechanical  injuries,  such  as  burns  or  scalds  from  hot  iron,  molten 
lead,  strong  acids,  &c.  In  these  cases  there  is  generally  also  symble- 
pharon.  Blepharitis,  accompanied  by  ulcerations  at  the  edge  of  the 
lids  may  produce  it,  if  the  ulcers  are  situated  opposite  to  each  other  on 
the  two  lids,  and  kept  for  a  long  time  in  contact  by  the  eye  being- 
bandaged  (Stellwag). 

Before  an  operation  is  attempted  for  the  cure  of  anchyloblepharon, 
the  surgeon  should  ascertain  whether  or  not  symblepharon  co-exists, 
and  if  so,  what  is  its  extent,  and  whether  it  involves  the  cornea  or  not. 
For  if  the  hd  be  widely  adherent  to  the  cornea,  little  or  no  benefit  will 
accrue  from  an  operation.  If  a  small  opening  exists  at  the  nasal  side, 
or  if  the  anchyloblepharon  is  but  partial,  a  probe  should  be  passed  in 
underneath  the  hd,  so  as  to  ascertain  whether  any  adhesions  exist 
between  it  and  the  eyeball.  If  the  adhesion  between  the  eyelids  is 
complete,  the  best  way  of  determining  this  is  to  pinch  the  upper  eye- 
lid into  a  fold  so  as  to  draw  it  away  from  the  globe,  and  then  to  order 
the  patient  to  move  his  eye  in  different  directions,  when  we  can  easily 
estimate  the  freedom  of  the  movements.  We  should  also  examine  what 
perception  of  light  the  patient  still  enjoys,  in  order,  if  possible,  to 
ascertain  whether  the  cornea  and  retina  are  healthy  or  not. 

If  the  adhesion  between  the  eyelids  is  not  very  considerable,  con- 
sisting perhaps  of  one  or  more  small  bands,  it  should  be  simply  di- 
vided close  to  the  edge  of  the  lid.  In  order  to  prevent  re-adhesion  of 
the  sui'faces,  these  should  be  touched  with  collodion  (Haynes  Walton). 
If  the  anchyloblepharon  is  complete,  but  a  small  opening  exists  near 
the  nasal  portion,  a  grooved  director  should  be  passed  in  through  this, 
and  run  behind  the  adhesion,  which  is  to  be  divided  upon  it  with  a 
scalpel.  If  no  opening  exists,  the  operator  should  at  one  point  lift  up 
the  lids  from  the  eyeball  in  a  vertical  fold,  and  divide  the  adhesion  here, 
then  introduce  a  director  through  this  incision,  and  finish  the  operation 
with  its  aid. 


14.— INJURIES  OF  THE  CONJUNCTIVA. 

These  may  be  of  a  mechanical  or  chemical  nature.  The  former 
may  prove  injurious  by  their  contact  with  the  conjunctiva,  setting  up 
irritation  and  inflammation,  or  from  their  wounding  and  lacerating  this 
membrane.  The  foreign  bodies  most  frequently  met  with  on  the  con- 
junctiva are  bits  of  steel,  iron,  glass,  coal,  straw,  dust,  etc.,  which  may 
remain  lodged  on  its  surface,  or  become  more  or  less  deeply  embedded 
in  its  structure.     The  presence  of  a  foreign  body  in  the  eye  generally 

G 


82  DISEASES   OF   THE   CONJUNCTIVA. 

sets  Tip  at  once  severe  symptoms  of  ciliary  irritation.  The  eyelids  are 
spasmodically  contracted,  the  ocular  conjunctiva  becomes  injected,  and 
a  bright  rosy  zone  appears  round  the  cornea ;  there  is  also  much  pho- 
tophobia, lachrymation,  and  a  feeling  as  of  sand  and  grit  in  the  eye  or 
xmder  the  upper  lid.  Sometimes,  the  pain  and  ciliary  neuralgia  are  con- 
siderable, and  the  pupil  is  markedly  contracted.  If  the  foreign  body  is 
small,  and  simply  lies  on  the  conjunctiva,  the  movements  of  the  eyelids, 
the  rubbing  of  the  eye  by  the  patient,  and  the  copious  laclnymation  will 
often  suffice  to  extrude  it.  If  the  surgeon  suspects  the  presence  of  a 
foreign  body,  he  must  carefully  and  closely  examine  the  surface  of  the 
palpebral  conjunctiva  of  both  lids,  as  well  as  the  ocular  conjunctiva  and 
the  cornea.  The  lower  eyelid  is  to  be  depressed  by  the  fore  and  middle 
finger  so  as  to  bring  its  inner  surface,  and  especially  the  retro-tarsal 
fold,  well  into  view,  the  patient  being  at  the  same  time  directed  to 
look  upwards. 

The  upper  lid  is  next  to  be  well  everted,  and  its  lining  membrane 
thoroughly  scanned,  more  particularly  the  retro-tarsal  region,  within 
the  folds  of  which  the  foreign  body  often  lies  hidden,  and  may  easily 
escape  detection.  Cases  are  naiTated  in  which  an  undiscovered  foreign 
body  has  set  up  a  severe  and  obstinate  ophthalmia.  When  found,  the 
foreign  body  should  be  removed  with  the  spud,  which  should  be  in- 
serted beneath  it,  and  gently  lift  it  out.  If  it  has  got  somewhat  em- 
bedded in  the  conjunctiva,  Mr.  Haynes  Walton's  gouge  will  be  found 
very  serviceable.  If  the  foreign  body,  more  especially  shot  or  small 
splinters  of  glass  or  steel,  etc.,  are  bimed  in  the  conjunctiva,  their  exact 
situation  should  be  ascertained  by  lightly  passing  the  finger  over  the 
surface  of  the  conjunctiva,  and  they  should  then  be  excised  with  per- 
haps a  small  portion  of  the  latter.  Sometimes  impalpable  bits  of 
dust  or  dirt  get  upon  the  conjunctiva  and  set  up  a  good  deal  of  irrita- 
tion. The  lids  being  well  everted,  a  blunt  probe  should  be  passed  over 
their  lining  membrane  and  behind  the  retro-tarsal  fold,  which  will 
sweep  off  any  such  portions.  The  surface  of  the  conjunctiva  should 
then  be  washed  by  a  stream  of  luke-warm  water,  directed  upon  it  from 
a  sponge  or  a  syringe.  If  sand  or  grit  has  got  into  the  eye  it  should 
also  be  washed  away  in  this  manner.  After  the  removal  of  a  foreign 
body  a  little  castor  or  olive- oil  should  be  dropped  into  the  eye,  and  if 
there  has  been  great  irritation  cold  compresses  should  be  applied  to  the 
lids. 

Chemical  injuries  may  produce  a  more  or  less  extensive  abrasion  of 
the  epithelium,  or  excoriation  of  the  sur-face  of  the  conjunctiva ;  if  the 
injury  was  severe  or  the  chemical  agent  very  strong,  a  deep  slough  of 
this  membrane  may  occur,  which  in  cicatrizing,  will  cause  a  considerable 
contraction  of  the  neighbouring  tissues.  Plastic  lymph  is  eflfused  and 
the  opposite  raw  surfaces  of  the   conjunctiva  become  closely  adlierent, 


TUMOURS   OF   THE   CONJUNCTIVA.  83 

hence  these  injuries  so  frequently  give  rise  to  symblepharon  and  an- 
chyloblepharon.  Sometimes  deep  and  obstinate  ulcers  are  formed,  the 
surface  of  which  becomes  covered  "with  sprouting  granulations. 

Injuries  from  lime  are  unfortunately  of  very  common  occurrence, 
and  are  very  dangerous  in  their  natui'e,  for  this  agent  is  very  strongly 
irritant,  producing  not  only  destruction  of  the  epithelium  and  the  sur- 
face of  the  conjunctiva,  but  more  or  less  deej?  and  extensive  sloughs 
of  this  membrane  and  of  the  cornea.     It  therefore  frequently  destroys 
the   sight,  or   in  more    favourable   cases    gives  rise  to    an  extensive 
symblepharon.     If  the  patient  is    seen    at  once,   a  weak    solution    of 
vinegar  and  water  (5j,  to  3J  of  water),  or  of  dilute  acetic  acid  should  be 
very  freely  injected  under  the  lids ;  this  will   produce  an  innocuous 
acetate  of  lime.     Then  a  few  drops  of  olive  or  castor-oil   should  be 
applied  to  the  eye  so  as  to  lubricate  the  surface  of  the  conjunctiva, 
and  the  surgeon,  everting  both  lids,  should  proceed  to  remove  every 
particle    of  lime.      This  having  been  done,  the    eye   should    be  well 
washed  by  letting  a  stream  of  luke-warm  water  from  a  sponge  or 
syringe  play  upon  the   surface  of  the  conjunctiva.     A  few  drops  of 
olive-oil  should  be  applied  three  or  four  times   a  day.     The  eschars 
which  form  on  the  conjunctiva  must  be  removed  with  a  pair  of  forceps. 
If  there  is  much  conjunctivitis  with  a  muco-purulent  discharge,  mild 
astringent    collyria  of  sulphate  of  zinc,   or  nitrate  of  silver  must  be 
employed,  or  the  eye  may  be  frequently  washed  with  a  glycerine  lotion 
(Glycerin  ^j  ad.  Aq.  dest.  B'^j)?  ^  little  being  allowed  to  flow  into  the 
eye.     But  when  the  sloughs   are   detached,  astringents  should  not  be 
used,  as  they  will  excite  too  much  irritation.     Nor  should  they  be  used 
if  the  eye  is  very  irritable  and  painful,  and  the  cornea  is  affected.     In 
such  cases  soothing  applications  are  indicated,  such  as  the  belladonna- 
lotion,  compound  belladonna-ointment  riibbed  on  the  forehead,  poppy 
fomentations,  etc. 

Strong  acids,  such  as  the  sulphui'ic  or  nitric,  produce  extensive 
sloughing  of  the  conjunctiva  and  cornea,  accompanied  by  severe 
sjTuptoms  of  irritation.  Generally,  however,  the  eyehds  suffer  the 
most,  and  the  deep  sloughs  which  may  be  produced,  frequently  give 
rise  to  entropion. 

After  an  injury  from  strong  acids,  the  eye  should  be  syringed  out 
with  a  weak  solution  of  carbonate  of  soda  or  potass  (3j  to  3iv — vi  Aq. 
distill),  in  order  to  neutralize  the  acid.  Afterwards  olive-oil  is  to  be 
dropped  in. 

15.— TUMOURS  OF  THE  CONJUNCTIVA,  ETC. 

Polypi  are  occasionally  met  with  in  the  conjunctiva,  especially  at  the 
semilunar  fold  or  caruncle.     They  appear  in  the  form  of  small  pink 

"g  2 


84  DISEASES   OF   THE   CONJUNCTIVA. 

lobulated  elevations  or  excrescences,  and  have  a  distinct  pedicle. 
Although  they  are  generally  small,  they  may  reach  the  size  of  a  hazel 
nut,*  and  protrude  between  the  aperture  of  the  lids.  They  may  be 
readily  snipped  off  with  a  pair  of  curved  scissors,  or  a  scalpel,  but  are 
apt  to  bleed  rather  freely.  The  hoemorrhage  may,  however,  be  easily 
arrested  by  a  light  touch  with  a  crayon  of  nitrate  of  silver,  which  will, 
moreover,  check  the  tendency  to  a  recurrence  of  the  disease. 

Pingueculae  might  be  mistaken  by  a  superficial  observer  for  a  slightly 
developed  pterygium,  as  it  is  a  small  triangular  elevation,  situated  gene- 
rally close  to  the  edge  of  the  cornea,  towards  which  its  base  is  turned. 
It  occurs  at  the  outer  or  inner  edge  of  the  cornea,  and  is  due  to  an 
hypertrophy  of  the  conjunctival  and  subconjunctival  tissue,  as  well  as 
of  the  epithelial  cells,  but  it  does  not  contain  any  fat,  as  might  have 
been  suspected  from  its  yellow  tint.  It  is  chiefly  met  with  in  old 
persons,  and  is  due  to  a  chronic  irritation  of  the  conjunctiva.  It  gene- 
rally remains  small  and  stationary,  and  produces  no  particular  incon- 
venience or  disfigurement.  Should  it,  however,  increase  in  size,  or  its 
appearance  prove  disagreeable  to  the  patient,  it  may  easily  be  excised. 

Fatty  tumours  are  of  rare  occurrence,  and  are  most  frequently 
observed  on  the  ocular  conjunctiva  at  some  little  distance  from  the 
cornea,  and  between  the  recti  muscles,  more  especially  the  superior  and 
external  rectus  in  the  vicinity  of  the  lachrymal  gland.  They  are  often 
due  to  an  hypertrophy  and  extension  of  the  adipose  tissue  of  the  orbit. 
They  appear  in  the  form  of  smooth,  yellow,  lobulated,  elastic  tumours, 
and  may  reach  a  considerable  size.  They  are  mostly  congenital,  and  do 
not  become  very  noticeable,  or  increase  greatly  in  size  until  a  much  later 
period.  When  they  attain  a  considerable  size  they  may  push  the  eyeball 
aside,  and  by  pressure  impede  the  functions  of  the  lachrymal  gland. 

If  the  tumour  is  inconsiderable  in  size,  it  may  be  easily  removed, 
but  care  should  be  taken  to  preserve  the  conjunctiva  as  much  as  possible, 
and  the  incision  should  be  closed  by  a  fine  suture. 

Dermoid  tumours  are  not  of  unfrequent  occurrence.  They  are 
situated  at  the  limbus  conjunctivae,  partly  on  the  cornea,  and  partly  on 
the  sclerotic,  are  of  a  pale,  whitish-yellow  colour,  about  one  or  two  lines 
in  diameter,  and  somewhat  raised  above  the  level  of  the  cornea.  The 
surface  of  the  tumour  is  generally  smooth,  but  it  may  be  lobulated,  and 
from  it  one  or  two  short  hairs  may  protrude.  Wardropf  mentions  an 
extraordinary  case  in  which  twelve  very  long  hairs  grew  from  the 
middle  of  the  tumour,  passed  through  between  the  eyelids,  and  hung 
over  the  cheeks ;  these  hairs  had  not  appeared  till  the  patient  was 
16  years  of  age,  at  which  time  his  beard  also  began  to  grow.  The 
tumour   is   generally    congenital,    and    almost    completely   stationary, 

*  Graefe,  A.  f.  O.  i,  1,  289. 

t  Wardrop's  "  Morbid  Anatomy  of  the  Human  Eye." 


TUMOURS   OF   THE   CONJUNCTIVA.  85 

increasing  very  slowly  in  size  with  the  growth  of  the  body.  It  may, 
however,  become  developed  later  in  life,  and  augment  considerably  in 
size.  The  largest  tumour  of  the  kind  that  I  have  met  with  I  saw  in 
Von  Graefe's  cliniqiie,  in  1860.  It  extended  over  the  outer  two-thirds 
of  the  cornea,  was  prominent,  lobulated,  and  very  disfiguring,  almost 
hiding  the  coi'nea.  From  their  close  analogy  to  the  structiire  of  the 
skin,  these  tumours  have  been  called  "dermoid."  They  sometimes, 
however,  appear  to  consist  only  of  elastic,  fibrillar,  connective  tissue, 
rudiments  of  true  skin,  fat,  hairs,  and  sebaceous  follicles.  Marked 
increase  in  their  size,  or  recurrence  after  removal,  appears  to  be  due  to 
an  increase  in  their  fatty  constituents.  They  may  be  readily  excised, 
but  care  must  be  taken  not  to  endeavour  to  remove  them  thoroughly 
from  the  cornea,  as  they  sometimes  extend  deeply  into  its  structure.* 

Warts  are  occasionally  seen  on  the  conjunctiva,  forming  small,  red, 
flesh-coloured  excrescences,  being  met  with  either  singly,  or  in  little 
clusters.  They  may  occur  on  the  palpebral  or  ocular  conjunctiva,  and 
also  on  the  semi-lunar  fold,  and  bear  a  strong  resemblance  to  the  warts 
upon  the  prepuce.  They  are  generally  accompanied  by  a  certain  degree 
of  conjunctivitis,  and  a  thin  muco-purulent  discharge.  They  should  be 
at  once  snipped  off  with  scissors  before  they  attain  any  size,  or  have 
time  to  spread,  and  if  necessary,  the  cut  portion  should  be  lightly 
touched  with  nitrate  of  silver. 

Cysts  of  the  conjunctiva  may  be  readily  distinguished  by  their  cir- 
cumscribed round  form,  and  their  pink,  translucent  appearance,  the 
transparency  of  their  contents  being  easily  recognised  with  the  oblique 
illumination.  They  may  occur  in  different  portions  of  the  conjunctiva, 
and  vary  in  size  from  a  small  pea  to  that  of  a  hazel  nut,  or  even  exceed 
this.  If  they  extend  into  the  orbit,  and  attain  a  considerable  size,  they 
cause  more  or  less  protrusion  of  the  eyeball.  The  walls  of  the  smaller 
cysts  are  generally  very  thin,  and  only  so  slightly  connected  with  the 
conjunctiva  that  they  may  be  very  readily  removed. 

Cysticerci  have  been  found  several  times  beneath  the  ocular  con- 
junctiva, and  in  one  instance  (Sichel)  beneath  the  palpebral.  There 
is  seen  at  some  part  of  the  ocular  conjunctiva,  near  the  angle  of  the 
eye,  a  transparent,  cyst-like  elevation,  which  is  round,  sharply  defined, 
and  somewhat  moveable,  and  varies  in  size  from  a  pea  to  a  small  bean. 
The  conjunctiva  over  the  cyst,  and  in  its  vicinity,  is  somewhat  hyper- 
semic,  but  if  it  is  sufficiently  thin  and  transparent,  we  may  be  able  to 
distinguish  at  the  outer  wall  of  the  cyst  a  peculiar  yellow  or  greyish- 
white  spot,  which  is  the  head  and  neck  of  the  entozoon,  and  Sichelf 
states  that  this  appearance  is  quite  characteristic. 

*  Vide  Graefe's  articles  "  On  Dermoid  Tumours,"  A.  f.  O.  vii,  2,  and  xii,  2,  227. 
t  "  Iconographie  Oplithalmologique,"  p.  702. 


86  DISEASES   OF   THE   CONJUNCTIVA. 

Cancerous  tumours  are  sometimes  met  with  as  primary  affec- 
tions, but  far  more  frequently  as  secondary  diseases,  after  cancer  of  the 
lids  or  the  eyeball. 

Epithelial  cancer  does  not  occur  as  a  primary  disease  in  the  con- 
junctiva, but  generally  extends  from  the  eyelids.  It  appears  as  a  small, 
smooth,  or  slightly  nodulated  excrescence  or  button,  at  the  edge  of  the 
cornea,  and  often  bears  a  very  striking  resemblance  to  a  pustule  or 
phlyctenula.  It  may,  however,  be  distinguished  from  the  latter  by  the 
absence  of  all  inflammatory  chemosis  and  irritation,  and  arterial  injection, 
only  a  few  dilated  tortuous  veins  converging  towards  the  little  tumour, 
together  with  a  slight  serous  infiltration.  Subsequently  the  tumour 
increases  in  size,  and  assumes  a  redder  tint,  and  its  surface  becomes 
more  nodulated  (cauliflower  excrescences),  being  covered  by  dry, 
thickened  epithelium ;  or  there  may  be  a  breach  of  surface,  and  a  thin, 
maco-purulent  discharge  exude  from  the  ulcer.  The  tumour  may 
invade  the  cornea  to  a  considerable  extent,  but  is  generally  but  slightly 
adherent  to  it,  so  that  it  may  be  nearly  entirely  removed.  It  may, 
however,  produce  a  dense  opacity  of  the  cornea  beyond  the  limits  of 
the  tumour,  or  lead  to  deep  and  extensive  ulceration,  or  even  perforation. 
If  the  tumour  is  stalked,  it  may  be  freely  moveable  upon  the  surface  of 
the  cornea.  Like  all  cancerous  tumours,  it  should  be  removed  at  the 
earliest  jDossible  period,  and  the  edges  of  the  conjunctival  wound  shoidd 
be  closed  with  fine  sutures,  in  order  that  the  sclerotic  may  not  be 
exposed.  It  is,  however,  very  apt  quickly  to  recur,  when  the  operation 
should  be  repeated  without  loss  of  time.  But  if  the  tumour  has 
invaded  the  cornea  to  a  considerable  extent,  is  intimately  connected  with 
its  tissue,  and  has  greatly  impaired  the  sight,  it  will  be  better  to  ex- 
cise the  eye ;  but  even  tliis  does  not  always  guard  against  recuri'ence, 
the  new  groAvth  springing  from  the  lids,  or  from  the  bottom  of  the  orbit. 
In  such  cases  it  is,  therefore,  always  advisable  to  apply  the  chloride 
of  zinc  paste  to  the  orbit,  after  the  removal  of  the  lids. 

Medullanj  cancer  almost  always  extends  to  the  conjunctiva  fi'om  the 
lids  or  from  the  eyeball  itself,  the  cornea  or  sclerotic  giving  way,  and 
the  tumour  sprouting  forth  and  very  rapidly  spreading  thence  into  the 
neighboui'ing  tissues. 

Melanotic  cancer  appears  in  the  form  of  a  small  darkish-red  or 
brownish-black  spot  or  tumour  in  the  subconjunctival  tissue  near  the 
cornea,  or  at  the  semilunar  fold  or  caruncle.  As  it  increases  in  size  it 
may  implicate  the  lids,  extending  beneath  them  and  giving  rise  to  more 
or  less  extensive  adhesions.  The  tumour  may  remain  stationary  for  a  long 
period  and  then  rapidly  increase,  and  it  is  very  prone  quickly  to  recur 
after  removal.  It  must  be,  however,  remembered  that  many  of  the 
little  black  tumours  which  are  often  erroneously  called  melanotic  cancer, 
are  only  sarcoma. 


TUMOURS   OF   THE   CONJUNCTIVA.  87 

Syphilitic  uJcers*  are  sometimes  met  with  on  the  conjunctiva,  being 
almost  always  situated  at  the  edge  of  the  lid,  and  they  bear  a  strong 
resemblance  to  a  chancre  upon  the  prepuce  ;  in  very  rare  instances  they 
may  occur  at  the  edge  of  the  cornea.f  We  shall  enter  more  fully  into 
theii'  description  when  speaking  of  the  syphihtic  ulcers  of  the  eyelids. 

Ncevi  sometimes  extend  from  the  external  portion  of  the  eyelid  to  the 
palpebral  or  even  ocular  conjunctiva,  and  may  reach  a  very  considerable 
size  if  they  are  not  treated  at  an  early  period.  They  may,  however, 
occur  primarily  on  the  conjunctiva  or  the  semi-lunar  fold,  and  should 
be  removed  as  early  as  possible. 

LHhiasis  is  a  term  applied  to  a  hardening  or  calcification  of  the 
secretion  of  the  conjunctival  glands,  more  especially  the  Meibomian 
glands.  The  affection  appears  in  the  form  of  wliite  round  concretions 
of  the  size  of  a  pin's  head,  which  may,  however,  attain  a  much  larger 
size  on  the  inner  surface  of  the  conjunctiva.  They  occur  either  singly, 
being  scattered  about  over  the  surface  of  the  lid,  or  they  may  appear 
arranged  in  single  file  along  the  tract  of  the  ducts  leading  from  the 
gland.  The  latter  is,  however,  much  more  rare.  On  account  of  the 
roughness  which  they  produce  on  the  lid,  considerable  irritation  and 
even  a  certain  degree  of  conjunctivitis  may  be  set  up.  The  little 
calcuH  are  easily  removed  by  incising  the  conjunctiva  over  them,  and 
lifting  them  out  with  the  point  of  a  cataract  needle,  or  a  grooved 
spatula.  Sometimes  the  concretion  is  soft  and  semi-transparent,  and 
appears  at  the  opening  of  the  duct,  whence  it  may  be  readily  pressed  out. 

The  secretions  of  the  caruncle  also  sometimes  undergo  cretification ; 
chalky  deposits  are  likewise  met  with  in  the  caruncle,  often  giving  rise 
to  irritation  and  swelling. 

Hcemorrhage  into  the  conjtinctiva  is  generally  produced  by  blows  or 
falls  upon  the  eye  or  face,  or  by  severe  straining  as  in  coughing,  sneezing, 
etc.,  which  cause  a  rupture  of  some  of  the  minute  blood-vessels  of  the 
conjunctiva.  Such  ecchymoses  are  also  often  met  with  in  the  course  of 
inflammations  of  the  conjunctiva,  or  in  persons  suffering  from  scurvy. 
In  other  cases  they  occur  spontaneously  without  any  apparent  cause ;  I 
have  met  with  several  instances  of  this  kind  in  which  the  ecchymosis 
had  come  on  during  the  night.  But  the  effusion  of  blood  may  not  be 
due  to  a  rupture  of  any  of  the  conjunctival  blood-vessels,  but  have 
gradually  made  its  way  forwards  from  the  orbit  beneath  the  conjunctiva. 
Thus  a  blow  upon  the  skull  may,  by  a  centre- coup,  pi'oduce  a  fracture 
of  some  portion  of  the  walls  of  the  orbit,  this  is  followed  by  more  or 
less  severe  haemorrhage,  and  the  effused  blood  may  make  its  way 
forwards  beneath  the  conjunctiva.  The  ecchymosis  does  not,  however, 
in  such  cases  appear  directly  after  the  accident,  but  only  at  an 
interval  of  several  hours. 

*  "  British  Med.  Journal,"  March  18,  18G5.  f  Wecker,  i,  177. 


88  DISEASES   OF   THE   CONJUNCTIVA. 

The  ecchymoses  are  generally  situated  on  the  ocular  portion  of  the 
conjunctiva  in  the  vicinity  of  the  cornea,  or  in  the  retro-tarsal  fold. 
The  effusion  mostly  gives  rise  to  uniformly  red  patches,  which  vary  in 
size  and  number,  but  it  may  be  so  considerable  that  it  extends  round  the 
whole  cornea. 

The  treatment  should  consist  chiefly  in  the  application  of  stimulating 
lotions,  e.g.,  Tr.  Arnic  5i-)  Aq  dist.  ^iv.,  to  be  applied  to  the  eye,  or  a 
compress  moistened  with  this  lotion  should  be  firmly  tied  over  the  eye ; 
indeed  a  firm  compress  bandage  accelerates  the  absoi'ption  of  blood 
more  than  any  other  remedy. 

(Edema  of  the  conjunctiva  is  met  with  very  fi-equently  in  the  course 
of  many  inflammations  of  the  conjunctiva  and  inner  tunics  of  the  eye, 
but  it  may  occur  also  spontaneously,  more  especially  in  elderly,  feeble 
persons  affected  perhaps  with  disease  of  the  kidney.  The  treatment 
should  consist  in  the  application  of  a  firm  bandage,  and  the  use  of  mild 
astringent  collyria.  A  few  superficial  incisions  may  be  made  in  the 
chemosis  with  a  pair  of  curved  scissors.  The  health  of  the  patient  should 
be  at  the  same  time  attended  to. 

Subconjunctival  emplhysema  is  caused  by  fracture  of  the  nasal  parietes 
which  admits  the  air  into  the  subconjunctival  tissue,  or  by  a  rupture  in 
the  lachrymal  sac ;  when  the  air  is  also  admitted  beneath  the  conjunc- 
tiva, if  the  nose  is  blown.  The  nature  of  the  affection  may  be 
recognised  by  the  peculiar  crackling  which  is  heard  when  the  swelling 
is  pressed  with  the  finger  ;  firm  pressure  will  cause  it  to  disappear.  A 
bandage  should  be  applied,  and  if  necessary  the  swelling  may  be  pricked 
with  a  needle  and  the  air  allowed  to  escape. 


Chapter   II. 
DISEASES    OF    THE    COENEA. 


l.—P  ANNUS. 


This  affection  is  cliaracterised  by  a  superficial  vascular  opacity  of  the 
cornea,  occupying  more  or  less  of  its  expanse.  The  opacity  generally 
commences  at  the  periphery,  and  gradually  extends  towards  the  centre, 
but  the  reverse  may  also  occur.  It  is  due  to  the  formation  of  a  neo- 
plastic layer  of  cells  beneath  the  epithelium,  and  also  perhaps  in  the 
superficial  layers  of  the  cornea  jiist  beneath  the  anterior  elastic  lamina 
(membrane  of  Bowman).  These  neo-plastic  cells  show  a  tendency  to 
become  developed  into  connective  tissue  (Wedl),  and  blood-vessels 
appear  amongst  them.  The  blood-vessels  are  situated  beneath  the 
epithehum,  and  also  somewhat  deeper,  beneath  the  anterior  elastic 
lamina.  On  closer  examination,  they  will  be  found  to  consist  of  two 
sets.  The  one  is  a  direct  continuation  of  the  conjunctival  vessels,  and  is 
almost  entirely  venous.  It  forms  a  large-meshed,  tortuous  network  of 
vessels,  covering  a  considerable  portion,  or  perhaps  even  the  whole  of 
the  cornea,  which  is  seen  to  be  opaque  and  hazy  between  the  naeshes. 
The  other  vessels,  which  are  chiefly  arterial,  are  straight  and  parallel, 
and  He  beneath  those  from  the  conjunctiva.  They  proceed  from  the 
anastomosis  between  the  conjunctival  and  subconjunctival  vessels,  at 
the  limbus  conjunctivae,  where  it  forms  a  bright  rosy  zone.  If  the  vas- 
cularity is  considerable,  these  parallel  vessels  are  very  numerous,  and 
give  a  very  I'ed  appearance  to  the  edge  of  the  cornea,  which  is  often 
also  somewhat  swollen.  When  the  cornea  is  extremely  vascular  and 
opaque,  so  that  it  assumes  a  very  red  or  even  fleshy  appearance,  the 
disease  is  termed  ^^ joanmos  crassus,^'  whereas  if  the  blood-vessels  are 
few  and  scattered,  and  the  cloudiness  inconsiderable,  it  is  called  '■^ pannus 
tenuis.'''' 

In  the  acute  form  of  the  disease,  there  is  often  considerable  photo- 
phobia, lachrymation,  and  ciliary  neuralgia,  accompanied  by  marked 
conjunctival  and  subconjunctival  injection.     But  if  the  affection  runs  a 


90  DISEASES   OF   THE   CORNEA. 

very  protracted  and  chronic  course,  the  irritability  of  the  eye  is 
generally  but  shght,  except  if  acute  exacerbations  occur.  The  surface 
of  the  cornea  gradually  becomes  more  opaque,  rough,  and  irregular, 
and  its  epithelial  layer  hypertrophied  and  thickened,  so  that  the 
cornea  may  finally  assume  almost  a  cuticular  appearance.  Or  the  epi- 
thelium may  be  shed  at  different  points,  giving  rise  to  superficial  facets 
and  irregularities.  But  the  loss  of  substance  may  extend  much  deeper, 
and  extensive  ulcers  be  formed,  which  may  even  lead  to  perforation  of 
the  cornea,  and  subsequently  to  anterior  synechia,  staphyloma,  etc. 
After  the  pannus  has  existed  for  some  time,  the  cornea  is  apt  to  become 
somewhat  thinned,  and  yielding  gradually  to  the  intra-ocular  pressure, 
lose  its  normal  curvature,  and  become  bulged  forward.  This  fact  is  of 
great  practical  importance,  for  even  although  the  cornea  should  here- 
after regain  much  of  its  transparency,  this  faultiness  in  its  curvature 
will  produce  considerable  deterioration  of  vision. 

Amongst  the  causes  which  may  produce  pannus,  granular  ophthal- 
mia is  by  far  the  most  frequent ;  in  fact,  in  the  vast  majority  of  those 
cases  in  which  the  opacity  is  confined  to  the  upper  half  of  the  cornea,  it 
is  due  to  granular  lids.  When  speaking  of  granular  ophthalmia,  I 
mentioned  that  pannus  might  be  produced  by  the  friction  of  the 
roughened  sui'face  of  the  lid  on  the  cornea,  or  by  a  dii'ect  extension  of 
the  granulations  on  to  the  ocular  conjunctiva,  and  from  thence  on  to  the 
cornea.  In  the  latter  case,  small  grey  or  yellow  infiltrations  appear 
near  the  margin  of  the  cornea,  and  if  the  attack  be  acute,  may  even 
extend  over  the  whole  of  the  cornea.  BetAveen  these  infiltrations  blood- 
vessels are  seen  to  be  passing. 

Phlyctenular  or  purulent  ophthalmia  may  also  give  rise  to  pannus. 
In  the  former  case,  the  opacity  and  vascularity  are  not  considerable  in 
extent,  and  the  affection  is  chiefly  characterised  by  the  appearance  of 
scattered  phlyctenulfe,  or  small  infiltrations  on  the  surface  of  the 
cornea. 

The  disease  may  also  be  produced  by  the  constant  fiiction  and  irri- 
tation of  the  cornea,  caused  by  inverted  eyelashes,  with  or  without 
entropion,  by  cretification  of  the  Meibomian  glands  (chalazion),  by  the 
desiccation  and  exposure  of  the  cornea  to  external  irritants,  as  in  cases 
of  lagophthalmus,  etc.  In  such  cases  the  disease  may  be  termed 
"  traumatic  pannus."  In  the  chronic  form,  pannus  may  exist  for  many 
years  -without  undergoing  any  particular  change,  except  perhaps  thinning 
and  prominence  of  the  cornea.  Inflamruatory  exacerbations  may,  how- 
ever, occur  again  and  again,  and  each  time  leave  the  sight  and  the 
opacity  of  the  cornea  in  a  worse  condition. 

The  prognosis  is  favourable  in  proportion  as  the  pannus  is  incon- 
siderable and  of  recent  origin,  and  the  cause  remediable.  In  very 
chronic  cases,  especially  of  the  pannus  crassus,  the  disease,   even  if 


PHLYCTENULAR  CORNEITIS  (HERPES  CORNER).       91 

eventually  cured,  generally  leaves  behind  it  extensive  and  dense  opaci- 
ties. If  there  is  a  central  leucoma,  or  if  iritis  has  occurred  duinng  the 
progress  of  the  disease,  and  the  pupil  is  closed,  it  will  be  necessary  to 
perform  iridectomy. 

The  treatment  to  be  adopted  must  depend  upon  the  cause,  for  if  the 
latter  can  be  cured,  the  pannus  will  also  disappear.  As  I  have  already 
in  the  article  upon  granular  ophthalmia  entered  very  fully  into  the 
mode  of  treating  pannus  produced  by  that  disease,  I  need  not  recur 
to  this  subject.  In  cases  of  traumatic  pannus,  our  efforts  must  be 
at  once  directed  to  the  removal  of  the  cause,  e.g.,  the  entropion, 
inverted  lashes,  chalazion,  etc.  The  opacity  of  the  cornea  which  may 
remain  after  the  disappearance  of  the  original  disease,  must  be  treated 
by  mild  local  iiTitants,  amongst  which  may  be  especially  recommended 
insufflation  of  calomel,  the  application  of  the  red  or  yellow  precipitate 
ointment,  viuum  opii,  oil  of  turpentine,  sulphate  of  copper,  etc.  These 
applications  hasten  the  absorption  of  the  mc>rbid  products,  by  pro- 
ducing a  temporary  inflammatory  congestion  of  the  blood-vessels. 


2.— PHLYCTENULAR  CORNEITIS  (HERPES  CORNER). 

This  disease  often  accompanies  phlyctenular  ophthalmia.  In  fact 
the  two  affections  are  alike  in  character,  and  demand  a  very  similar 
mode  of  treatment. 

As  in  phlyctenular  ophthalmia,  the  appearance  of  the  vesicles  on  the 
cornea  is  generally  preceded  by  a  sensation  of  heat  and  itching  in  the 
eyehds,  which  is  soon  followed  by  conjunctival  and  sub-conjunctival 
injection,  photophobia,  lachrymation,  and  ciliary  neuralgia.  The  latter, 
which  is  often  but  slight  when  the  affection  is  confined  to  the  conjunc- 
tiva, is  frequently  very  severe  in  herpes  cornese.  The  same  is  the  case 
with  the  photophobia,  which  is  often  most  intense  and  persistent.  The 
characteristic  little  phlyctenulse  soon  make  their  appearance  on  the 
surface  of  the  cornea.  Their  number  and  mode  of  distribution  vary 
greatly.  Sometimes,  there  are  but  one  or  two  near  the  margin  of  the 
cornea,  in  other  cases  they  are  more  numerous,  and  are  either  scattered 
freely  over  the  surface  of  the  cornea,  or  are  chiefly  confined  to  one  part. 
Or  again,  they  may  be  ranged  along  its  edge  in  single  file,  suiTounding 
a  more  or  less  considerable  portion  of  the  cornea  like  a  string  of  beads. 
If  the  phlyctenulae  are  numerous,  and  extend  over  a  considerable  expanse 
of  the  cornea  (pannus  scrofulosus),  the  vascularity  is  general,  and  the 
cornea  is  surrounded  by  a  bright,  rosy  zone  of  vessels ;  whereas,  if  the 
pustules  are  confined  to  one  portion  of  the  cornea,  the  injection  is 
generally  also  partial.  Sometimes,  the  phlyctenulse  are  very  superficial, 
and  appear  in  the  form  of  small,  transparent  vesicles  or  blisters,  whose 


92  DISEASES   OF   THE   CORNEA. 

epithelial  covering  is  soon  shed,  leaving  a  small  excoriation,  wliich  may 
easily  escape  detection,  and  lead  to  an  erroneous  diagnosis  and  mode  of 
treatment.  Grenerally,  however,  the  phlyctemila  is  more  apparent,  and 
is  imbedded  in  the  cornea,  its  summit  rising  slightly  above  the 
siu^face.  It  appears  in  the  form  of  a  small,  cii'cumscribed,  grey  infiltra- 
tion, surrounded  by  a  zone  of  slightly  opaque  and  swollen  cornea,  the 
latter  being  especially  the  case  if  several  phlyctenulae  are  situated  close 
together.  At  its  apex  a  little  transparent  vesicle  often  forms,  which 
bursts  and  leaves  an  excoriated  surface,  the  bottom  of  which  is  opaque,  and 
of  a  grey  or  greyish -yellow  colour.  This  excoriation  may  gradually  extend 
somewhat  in  ch'cumference  and  depth,  and  assume  the  character  of  a 
small  ulcer.  This  is  especially  apt  to  occur  if  the  phlyctenula  is  situated 
near  the  centre  of  the  cornea,  and  the  affection  has  been  injudiciously 
treated  by  strong  astringents.  If  no  transparent  vesicle  forms  at  the 
apex  of  the  phlyctenula,  this  becomes  somewhat  more  opaque  and  infil- 
trated, and  then,  losing  its  epithelial  covering,  becomes  changed  into 
a  superficial  yellowish  grey  ulcer.  These  ulcers  generally  run  a  very 
favourable  course  if  they  are  judiciously  treated,  and  show  little  or  no 
tendency  to  extend  much  either  in  circumference  or  depth.  The  ulcer 
becomes  covered  by  a  layer  of  epithelium,  and  gradually  fills  up,  and  the 
cornea  regains  more  or  less  of  its  transparency.  But  if  the  infiltrations 
are  situated  very  close  to  each  other,  two  or  three  may  coalesce,  and 
thus  give  rise  to  one  extensive  ulcer,  which  may  increase  in  depth,  and 
even  lead  to  perforation.  This  may  also  occur  if  the  infiltrations  are 
situated  somewhat  deeply  in  the  cornea,  and  if  strong  local  irritants 
(nitrate  of  silver,  sulphate  of  copper,  etc.)  are  employed.  In  the 
majority  of  cases  there  is  no  fear  of  this  complication,  for  under  judi- 
cious treatment  the  excoriations  or  little  ulcers  soon  fill  up,  the  corneal 
substance  is  regenerated,  and  perhaps  no  opacity  is  finally  left.  In  other 
cases  the  result  is  not  so  favourable,  for  a  more  or  less  dense  opacity  may 
remain  behind. 

There  is  a  great  tendency  to  relapses.  Just  as  the  symptoms  of  irri- 
tation and  vascularity  are  subsiding,  the  phlyctenulge  disappearing,  and 
the  disease  seems  to  be  almost  cui-ed,  all  the  acute  symptoms  of  irri- 
tation return,  a  fresh  crop  of  pustules  makes  its  appearance,  and  a 
severe  relapse  takes  place.  This  may  occur  again  and  again,  and  the 
affection  gradually  assume  a  chronic  character ;  vessels  are  developed 
upon  the  cornea,  which  run  towards  the  infiltration,  and  this  condition 
might  be  mistaken  by  a  superficial  observer  for  that  of  fascicular 
corneitis.  On  closer  examination  it  will,  however,  be  seen  that  the 
blood-vessels  are  few  in  number,  and  more  scattered,  do  not  rise  pro- 
minently above  the  surface  of  the  cornea,  and  do  not  push  along  the 
infiltration  before  them,  but  rather  stop  short  of  it.  When  numerous 
phlyctenules  are  crowded  together  on  the  cornea,  and  interspersed  with 


PHLYCTEXULAR  CORKEITIS  (HERPES  CORNER).       93 

blood-vessels,  it  is  often  termed  herpetic  or  scrofulous  pannus,  more 
especially  if  they  are  situated  in  the  upper  half  of  the  cornea. 

The  causes  which  may  produce  this  affection  are  the  same  as  those 
which  give  rise  to  phlyctenular  ophthalmia,  and  it  also  occurs  most  fre- 
quently amongst  chikb'en  and  young  persons  of  a  weakly,  scrofulous 
constitution,  and  nervous,  excitable  temperament. 

The  treatment  should  also  be  similar  to  that  which  was  recom- 
mended for  phlyctenular  ophthalmia.  I  must  here  lay  the  greatest  stress 
upon  the  necessity  of  avoiding  the  use  of  caustics,  more  especially  the 
nitrate  of  silver,  for  this  greatly  increases  the  irritability  of  the  eye, 
aggravates  the  character  of  the  disease,  and  augments  any  tendency  to 
necrosis  and  breaking  down  of  the  corneal  tissue.  It  may  also  cause 
the  inflammation  to  extend  to  the  ii"is  and  ciliary  body.  Indeed  it  may 
be  laid  down  as  a  rule,  that  in  all  affections  of  the  cornea,  except  those 
of  a  very  chronic  character,  the  use  of  caustics  should  be  most  strictly 
avoided.  In  phlyctenular  corneitis  our  chief  endeavour  must  be  to 
diminish  the  great  irritability  of  the  eye,  to  prevent  the  extension  of 
the  phlyctenulae  or  ulcers,  and  to  facilitate  and  assist  the  regeneration 
of  the  corneal  tissue.  The  agent  which  we  shall  find  of  the  greatest 
service  for  these  purposes  is  atropine.  Indeed  this  remedy  is  invaluable 
in  the  treatment  of  affections  of  the  cornea  and  iris.  It  exerts  a  bene- 
ficial influence  upon  the  cornea,  by  acting  as  a  local  anaesthetic  dui'ing 
its  passage  through  the  cornea  into  the  aqueous  humour,  thus  greatly 
diminishing  the  ii-ritability  of  the  cornea  and  of  the  ciliary  nerves. 
This  is  often  witnessed  when  a  drop  of  atropine  is  applied  to  an  eye 
affected  with  acute  corneitis,  accompanied  by  intense  symptoms  of  ii^ri- 
tation ;  for  if  such  an  eye  is  examined  half-an-hour  after  the  applica- 
tion of  the  atropine,  we  find  a  very  marked  diminution  in  all  these 
symptoms  ;  the  patient  expressing  himself  greatly  relieved.  The  atro- 
pine also  acts  by  decreasing  the  intra-ocular  tension,  and  thus  relieving 
the  cornea  of  a  certain  degree  of  pressure ;  hence  its  nutrition  and 
the  regeneration  of  its  substance  are  greatly  facilitated.  This  diminu- 
tion in  the  intra-ocular  tension  is  of  special  advantage  in  deep  ulcers  of 
the  cornea,  as  will  be  readily  understood  when  we  remember  that  the 
thinnest  portion  of  the  cornea  (the  bottom  of  the  ulcer)  has  to  sustain 
the  same  degree  of  intra-ocular  pressure  as  the  healthy  part.*     The 

*  I  must,  however,  strongly  insist  upon  the  absolute  necessity  of  the  solution  of 
atropine  being  quite  pure,  and  perfectly  fi'ee  fi-om  any  admixture  of  strong  acid  or 
spirits  of  wine.  A  few  drops  of  strong  sulphuric  acid  are  sometimes  added  by 
chemists  when  the  sulphate  of  atropine  is  not  quite  nevitral,  and  therefore  imper- 
fectly soluble.  I  have  met  with  several  instances  in  which  a  pure  solution  of  atro- 
pine proved  of  the  greatest  benefit  in  allaying  the  irritability  of  the  eye  and  in 
alleviating  the  inflammation,  and  in  which  a  fresh  supply  of  atropine  (made  up 
after  the  same  prescription,  but  obtained  from  a  different  chemist)  has  at  once  set  up 
severe  irritation  of  the  eye,  accompanied  by  considerable  pain,  redness,  lachryma- 


94  DISEASES  OF  THE  CORNEA. 

solution  of  atropine  (gr.  ij.  ad  3J  of  water)  should  be  applied  to  the  eye 
three  or  four  times  a  day.  If  it  should,  after  a  time,  be  found  rather  to 
increase  than  alleviate  the  irritation,  a  collyrium  of  belladonna  must  be 
substituted.  If  it  has  already  produced  considerable  irritation  of  the 
conjunctiva,  and  a  crop  of  vesicular  granulations,  an  astringent  colly- 
rium of  alum,  borax,  or  nitrate  of  silver  (gr.  j.  ad  §j)  should  be 
employed.  The  compound  belladonna  is  to  be  rubbed  on  the  forehead 
three  or  four  times  daily,  until  a  slight  papular  eruption  is  produced. 
If  there  is  much  pain  in  and  around  the  eye,  and  more  especially  if  the 
latter  is  very  painful  to  the  touch,  much  relief  is  often  experienced  from 
the  application  of  two  or  three  leeches  to  the  temple,  or  a  blister  may 
be  applied  behind  the  ear.  If,  together  with  the  photophobia  and  lachry- 
mation,  the  temperature  of  the  lid  is  much  increased,  I  have  often 
found  very  marked  benefit  from  the  periodical  application  of  cold  com- 
presses. These  are  to  be  applied  three  or  four  times  a  day,  for  a  space 
of  20  or  30  minutes,  and  are  to  be  changed  every  two  or  three  minutes, 
as  soon  as  they  get  the  least  warm.  The  photophobia  is  often,  however, 
very  obstinate  and  intractable.  When  it  is  chiefly  due  to  an  abrasion 
of  the  epithelium  and  exposure  of  the  corneal  nerves,  a  compress  band- 
age should  be  applied.  But  sometimes  it  resists  all  remedies,  and  a 
severe  spasm  of  the  lids  (blepharospasm)  remains  even  after  the  affection 
of  the  cornea  is  cured.  In  such  cases  the  different  remedies  which  I 
have  mentioned  in  the  article  on  phlyctenular  ophthalmia,  should  be 
tried,  viz.,  subcutaneous  injection  of  morphia,  immersion  of  the  face  in 
cold  water,  and  if  all  these  fail,  and  the  spasm  is  arrested  by  pressure 
upon  the  supra-orbital  nerve,  we  must  have  recourse  to  a  division  of  this 
nerve.  I  have  often  found  that  a  prolonged  stay  at  the  sea-side,  together 
vrith  sea-bathing,  tonics,  a  generotis  diet,  and  plenty  of  out-of-door 
exercise,  will  cure  cases  of  photophobia,  which  have  obstinately  resisted 
all  other  remedies. 

tion,  etc.,  but  these  symptoms  soon  disappeared  again  on  the  use  of  a  jpure  solution 
of  atropine.  On  examination,  the  impiu-e  solution  was  found  to  contain  a  small 
quantity  of  strong  sidphuric  acid.  Such  cases  as  this  completely  disprove  the 
theory  that  a  small  qviantity  of  strong  acid  or  of  alcohol  can  have  no  prejudicial 
effect  upon  the  eye,  even  although  there  may  be  much  ciliary  irritation  and  a  severe 
inflammation  of  the  cornea  or  iris.  I  must  state,  however,  that  we  occasionally 
meet  with  exceptional  cases,  in  which  there  exists  a  pecviliar  idiosyncrasy  which 
renders  the  patient  most  intolerant  of  the  use  of  even  a  weak  and  perfectly  pure 
solution  of  atropine.  I  have  seen  instances  in  which  a  drop  of  a  weak  and  quite  pm-e 
solution  of  atropine  has  produced  great  ii'ritation  and  pain,  or  even  an  erysipelatous 
condition  of  the  eyelids  and  cheek  accompanied  by  redness  and  chemotic  swelling  of 
the  conjunctiva.  This  is,  however,  a  very  exceptional  occurrence,  and  bears  not  the 
least  analogy  to  those  cases  in  which  the  irritation  is  caused  by  the  impm-ity  of  the 
atropine,  for  in  such  cases  a  pure  solution  of  atropine  is  not  only  well  borne,  but 
greatly  alleviates  the  ciliary  irritation  and  the  inflammatory  symptoms.  Mr.  Lawson 
also  mentions  some  interesting  instances  of  this  peculiar  idiosyncrasy,  in  a  paper  in 
the  "  R.  L.  O.  H.  Eeports,"  vi,  119. 


FASCICULAR   CORNEITIS.  95 

Small  doses  of  tartai-  emetic  sometimes  prove  useful  in  alleviating 
the  photophobia  and  ciliary  irritation  during  the  acute  stage  of  the 
disease.  But  this  remedy  should  not  be  persisted  in  if  it  does  not 
produce  any  benefit  in  the  course  of  a  few  days,  as  its  prolonged  use  is 
apt  to  weaken  and  debilitate  the  patient.  Arsenic  has  also  been 
strongly  recommended  in  this  form,  of  corneitis  on  the  supposition  of 
its  similarity  to  eczema.  This  remedy  often  proves  very  serviceable, 
especially  if  the  corneitis  is  accompanied  by  an  eczematous  eruption  of 
the  forehead  and  face.  In  the  latter  case  the  lotion  of  acetate  of  lead 
and  glycerine  (p.  67)  should  be  applied  to  the  face.  The  patient's 
general  health  should  be  attended  to,  and  if  he  is  of  a  weakly  and 
scrofulous  habit,  tonics,  cod-liver  oil,  and  a  nutritious  and  generous 
diet,  together  with  the  use  of  ale  and  wine,  should  be  prescribed.  The 
bowels  should  be  kept  well  regulated,  and  special  attention  should  be 
paid  to  the  free  action  of  the  skin,  as  this  exerts  a  marked  influence  upon 
the  symptoms  of  ciliary  irritation,  especially  the  photophobia.  "When 
the  acute  symptoms  have  subsided,  we  must  have  recourse  to  the  in- 
sufflation of  calomel,  and  if  this  is  well  borne  the  yellow  oxide  of  mer- 
cury ointment  (gr.  iv — viii,  ad  adip  3J)  should  be  applied  ;  this  will  not 
only  hasten  the  absorption  of  any  remaining  opacity,  but  check  the 
tendency  to  relapses.  In  chronic  and  very  obstinate  cases,  especially 
if  they  are  accompanied  by  much  vascularity  of  the  cornea,  great 
benefit  is  often  experienced  from  a  seton. 

In  rare  instances  we  meet  with  a  peculiar  formation  of  transparent 
vesicles  upon  the  surface  of  the  cornea,  which  are  produced  by  slight 
elevations  of  the  epithelial  layer  and  the  anterior  elastic  lamina  from 
the  surface  of  the  cornea  proper.  The  appearance  presented  by  these 
little  blisters  is  very  characteristic,  and  is  generally  accompanied  by 
very  severe  symptoms  of  ii'ritatiou,  especially  photophobia  and  lachry- 
mation.  These  symptoms  subside  when  the  vesicles  burst,  but  a  fresh  crop 
of  the  latter  is  generally  formed  every  three  or  four  days.  In  a  case  men- 
tioned by  Mooren  the  disease  assumed  the  character  of  a  regular  tei-tian 
type,  and  was  cured  by  the  energetic  use  of  quinine  ;  indeed  this 
remedy,  combined  perhaps  with  steel,  should  be  given  in  all  cases ; 
atropine  and  a  compress  bandage  being  applied  to  the  eye. 


3.— FASCICULAR  CORNEITIS. 

This  peculiar  form  of  corneitis,  which  is  very  common  in  Germany, 
is  extremely  rare  in  England,  for  whilst  I  saw  many  instances  of  it  in 
Berlin,  I  only  remember  having  met  with  four  pure  cases  in  England 
during  the  last  eight  years. 


96  DISEASES   OF  THE   CORNEA. 

The  symptoms  of  this  affection  are  very  characteristic  and  easily 
recognised.  The  attack  is  generally  ushered  in  by  considerable  photo- 
phobia, lachrymation,  and  ciliary  neuralgia.  On  examining  the  eye, 
the  ocular  conjunctiva  is  found  to  be  injected,  and  there  is  also  seen  a 
bright  rosy  zone  of  subconjunctival  vessels  around  the  cornea.  Near 
the  edge  of  the  latter,  may  perhaps  be  noticed  at  one  spot  a  few  small 
phlyctenulee,  and  the  linibus  conjunctivfe  is  at  this  point  also  somewhat 
swollen.  The  parallel  subconjunctival  vessels  are  seen  at  this  spot  to 
pass  on  to  the  cornea  and  extend  more  or  less  on  to  its  surface,  forming 
a  narrow  bundle  or  leash  of  vessels  (hence  the  term  "fascicular"  cor- 
neitis),  which  lies  in  a  somewhat  swollen  and  elevated  portion  of  the 
cornea.  This  fasciculus  of  vessels  consists  both  of  veins  and  arteries ; 
at  its  apex,  and  rising  somewhat  above  the  level  of  the  vessels,  is  noticed 
a  small,  crescentic,  yellowish-grey  infiltration,  surrounded  by  a  some- 
what opaque  and  swollen  portion  of  cornea.  As  the  disease  progresses, 
the  infiltration  is  gradually  pushed  further  and  further  on  to  the  cornea 
in  front  of  the  vessels ;  its  epithelial  covering  is  shed,  it  assumes  a 
yellowish  tint  and  becomes  changed  into  a  small  superficial  ulcer.  In 
some  instances  the  original  leash  of  vessels  may  bifurcate,  so  that  it 
assumes  a  Y  shape,  having  a  separate  infiltration  at  each  apex.  The 
disease  may  extend  far  on  to  the  cornea,  and  prove  dangerous  from  its 
leaving  a  dense  opacity  in  the  centre  of  the  cornea  just  over  the  pupil,  but 
the  ulcer  generally  remains  superficial,  and  does  not  extend  very  deeply 
into  the  cornea  or  lead  to  perforation.  During  the  progressive  stage,  the 
S}Tnptoms  of  irritation  are  very  marked  and  obstinate.  When  the  disease 
has  reached  its  acme,  it  generally  remains  stationary  for  some  little  time 
(perhaps  even  several  weeks)  and  then  gradually  diminishes  in  intensity 
and  slowly  retrogrades,  the  symptoms  of  ii^ritation  rapidly  disappearing. 
The  time  which  elapses  during  these  several  stages,  will  depend  upon 
the  size  of  the  fasciculus  of  vessels  and  of  the  infiltration.  The  vas- 
cularity gradually  diminishes,  the  ulcer  is  again  covered  by  a  layer  of 
epithelium  and  begins  to  fill  up  from  the  periphery  towards  the  centre  ; 
the  corneal  tissue  is  more  or  less  regenerated,  and  after  a  time  but 
little  opacity  may  be  left. 

This  disease  is  generally  due  to  the  same  causes  as  phlyctenular 
ophthalmia,  and  is  most  frequently  met  with  in  weakly  and  scrofulous 
persons,  and  in  thera  it  is  very  apt  to  run  a  most  protracted  course. 

If  the  symptoms  of  irritation  are  very  acute  only  soothing  reme- 
dies should  be  applied.  Atropine  should  be  dropped  into  the  eye, 
the  compound  belladonna  ointment  should  be  rubbed  in  over  the  fore- 
head, a  blister  should  be  applied  behind  the  ear,  and  a  leech  or  two 
to  the  temple  if  the  eye  is  very  painful  to  the  touch.  If  the  vas- 
cularity is  very  marked  and  the  case  severe,  benefit  is  often  derived 
from  dividing  the  bundle  of  vessels  close  to  the   cornea  either  with  a 


SUPPURATIVE   CORNEITIS.  07 

small  scalpel  or  a  pair  of  curved  scissors ;  after  this  has  been  done,  the 
blood-vessels  on  the  cornea  and  the  infiltration  are  found  to  shrink  and 
diminish  in  size.  When  the  acute  symptoms  of  irritation  have  con- 
siderably subsided,  the  insufflation  of  calomel  should  be  at  once  com- 
menced, or  the  yellow^  oxide  of  mercury  ointment  (gr.  ij — viii  ad  3J) 
should  be  applied.  Both  these  remedies,  but  more  especially  the  yellow 
oxide,  are  almost  specifics  for  this  disease.  The  ointment  may  be  ap- 
plied from  the  very  commencement,  if  the  symptoms  of  irritation  are 
not  very  marked  ;  it  must,  however,  be  used  with  care,  and  its  effect 
shoiild  be  closely  watched.  If  we  find  the  next  day  that  it  has  excited 
considerable  redness  and  irritation,  its  use  should  be  temporarily 
abstained  from,  and  calomel  should  be  substituted.  It  is  also  of  much 
use  in  checking  the  tendency  to  relapses,  in  cutting  these  short,  and  in 
hastening  the  absorption  of  the  corneal  opacity.  Frequently,  we  must 
ring  the  changes  between  the  ointment  and  the  calomel,  as  after  a  time 
they  temporarily  lose  some  of  their  effect. 

A  seton  at  the  temple  sometimes  also  proves  of  much  benefit  in 
this  affection,  not  only  in  shortening  the  course  of  the  disease,  but  also 
in  preventing  the  occuiTcnce  of  relapses. 

4.— SUPPURATIVE  CORNEITIS. 

Practically  it  is  of  importance  to  distinguish  two  principal  forms  of 
suppurative  corneitis.  The  one  is  accompanied  by  more  or  less  marked 
inflammatory  symptoms,  whilst  in  the  other  these  are  entirely  absent, 
and  the  chief  danger-  of  the  disease  is  found  in  their  absence,  as  the 
suppuration  spreads  very  rapidly  and  an  extensive  abscess  or  slough 
of  the  cornea  speedily  ensues.  These  two  forms  also  demand  a  totally 
opposite  plan  of  treatment.  In  the  inflammatory,  we  must  endeavour 
to  check  and  subdue  the  symptoms  of  irritation  and  inflammation  by 
local  ant iphlogi sties  ;  whereas  in  the  torpid,  non-inflammatory  form,  we 
must  most  carefully  eschew  such  treatment,  and  at  once  attempt  to 
produce  a  certain  degree  of  inflammation,  in  order  to  check  the  tendency 
to  necrosis  and  purulent  infiltration. 

"WHiilst  drawing  special  attention  to  these  two  opposite  tyjies  of 
the  disease,  I  must  state  that  in  practice  we  constantly  meet  with 
mixed  forms,  showing  some  of  the  symptoms  of  each  type.  Indeed  the 
surgeon  will  chiefly  display  his  skill  and  judgment,  by  distinguishing 
whether  any  of  the  symptoms  have  attained  an  undue  prominence  and 
require  to  be  checked,  in  order  that  a  just  balance  may  be  maintained 
between  the  necessary  degree  of  inflammation  and  the  suppui'ative 
condition  of  the  cornea ;  so  that  whilst  on  the  one  hand,  the  inflam- 
matory symptoms  are  not  allowed  to  become  excessive,  they  are,  on 
the  other,  not  too  much  suppressed. 


98  DISEASES   OF   THE   CORNEA. 

The  infla-mmatory  sujyjmrative  cornciUs    is    often    accompanied    by 
great  photojDliobia,  lachrymation,  and  intense  ciliary  neuralgia ;    there 
is  also  mucli  conjunctival  and  subconjunctival    injection,  the   cornea 
being  surrounded  by  a  bright  rosy  zone,  accompanied  perhaps  by  some 
chemosis.    On  account  of  the  irritation  of  the  ciliary  nerves,  the  pupil  is 
often  greatly  contracted.     On  examining  the  cornea  we  notice  a  small 
circumscribed  infiltration,  which  is  generally  situated  near  the  centre, 
but  sometimes  at  the  periphery  of  the  cornea.    Its  position  varies,  some- 
times it  is  situated  in  the  superficial  layers  of  the  cornea,  and  then  the 
latter  may  become  somewhat  raised  above  the  level  at  this  point,  or  it 
may  lie  in  the  central  or  deeper  portion  of  the  cornea,  in  which  case 
the  sui'face  remains  unaltered.      The  infiltration  soon  increases  in  density 
and  assumes  a  creamy  yellowish-grey  colour,  being  surrounded  by  a 
well  marked  line  of  demarcation  in  the  form  of  a  light  grey  zone,  which 
gradually  shades  off  into  the  transparent  cornea  ;  the  latter  also  shows 
a  certain  degree  of  inflammatory  swelling  at  the  point  occupied  by  this 
zone.     The  epithelium  may  be  shed,  and  a  portion  of  the  contents  of 
the  infiltration  break  down  and  be  thrown  ofi",  so  that  a  more  or  less 
deep  ulcer  is  formed.     Although  the  subconjunctival  vessels  may  pass 
slightly  on  to  the  cornea,  they  never  reach  the  ulcer,  even  when  this  is 
situated  near  the  periphery.    When  it  is  in  the  centre  of  the  cornea,  the 
latter  appears  quite  free  from  blood-vessels,  except  a  few  which  may 
just  pass  over  its  margin.     The  retrogressive  stage  generally  soon  sets 
in,  the  infiltration  changes  its  yellow  hue  for  a  light  grey  tint,  and 
becomes  gradually  absorbed,  leaving  perhaps  hardly  any  opacity  behind. 
The  disease  as  a  rule  shows  a  tendency  to  remain  localised,  and  not  to 
extend  superficially,  but  rather  in  depth.     Relapses  are  apt  to  occur 
and  the  afiection  may  thus  assume  a  chronic  character. 

But  the  disease  does  not  always  run  so  favourable  a  course.  Thus, 
several  superficial  infiltrations  may  be  formed  close  to  each  other, 
and  gradually  extending  in  circumference  and  depth,  may  coalesce 
and  thus  give  rise  to  a  considerable  abscess  of  the  cornea.  Their  con- 
tents undergo  suppurative  and  fatty  degeneration,  the  cells  and  nuclei 
break  down,  the  infiltration  assumes  a  yellow  colour,  surrounded,  how- 
ever, by  a  greyish- white  zone  of  demarcation.  If  this  occurs  near  the 
centre  of  the  cornea,  it  may  prove  dangerous  from  its  leaving  a  dense 
opacity  just  over  the  pupil,  or  from  its  perhaps  leading  to  an  extensive 
slough  of  the  cornea.  Again,  if  the  infiltration  is  situated  deeply  in 
the  cornea,  it  m^ay  lead  to  perforation  of  the  latter,  or  give  rise  to  onyx, 
hypopyon,  and  iritis.  The  pus  may  sink  down  between  the  lamellas  of 
the  cornea  to  its  lower  margin,  and  thus  give  rise  to  a  peculiar  opacity, 
termed  onyx  or  unguis,  on  account  of  its  supposed  resemblance  to  the 
white  lunula  of  the  finger-nail.  If  the  onyx  is  but  small,  and  con- 
fined to  the  very  edge  of  the  cornea,  it  may  easily  be  overlooked,  more 


SUPPURATIVE   CORNEITIS.  99 

especially  if  it  be  somewhat  covered  by  the  swollen  limbus  conjunctiva?. 
If  it  is  more  considerable,  so  that  it  reaches  nearly  up  to  one-third  of 
the  cornea,  or  even  higher,  it  may  be  mistaken  for  an  hypopyon.  But 
on  careful  examination  (more  especially  with  the  oblique  illumination) 
it  will  not  be  difficult  to  distinguish  it  from  the  latter,  for  it  will  be 
seen  to  lie  on  the  corneal  side  of  the  anterior  chamber,  a  portion  of 
transparent  cornea  perhaps  dividing  it  from  the  latter,  and  it  is  situated 
at  some  distance  from  the  iris.  But  the  differential  diagnosis  is  of 
course  more  difficult  if,  as  is  sometimes  the  case,  an  hypopyon  co-exists 
with  the  onyx. 

The  hypopyon  which  not  unfrequently  accompanies  suppurative 
corneitis  (more  especially  the  non-inflammatory  form)  may  be  produced 
either  from  the  iris  or  from  the  cornea  in  the  following  ways : — 

1.  An  inflammation  of  the  iris  may  supervene  upon  the  coi'neitis, 
lymph  be  eff'used  into  the  aqueous  humour,  and,  falling  to  the  bottom 
of  the  anterior  chamber,  thus  produce  an  hypopyon. 

2.  The  abscess  may  perforate  the  cornea,  and  its  purulent  contents 
be  carried  into  the  aqueous  humour  and  be  precipitated  at  the  bottom 
of  the  anterior  chamber.  Sometimes  such  a  mode  of  production  of 
hypopyon  is  completely  overlooked,  from  the  fact  that  the  communica- 
tion between  the  anterior  chamber  and  the  abscess  in  the  cornea  is  not 
large  and  direct,  but  is  brought  about  by  a  small  sloping  canal,  through 
which  the  contents  of  the  abscess  have  made  their  way  into  the  anterior 
chamber.  Special  attention  has  been  called  to  this  fact  by  Weber,* 
who  has,  moreover,  frequently  passed  a  minute  probe  from  the  ulcer 
through  the  canal  into  the  anterior  chamber,  and  thus  verified  the 
communication.  With  the  oblique  illumination,  this  little  canal  ap- 
pears like  a  white  streak,  running  from  the  abscess  to  the  anterior 
chamber. 

3.  When  the  abscess  is  situated  deeply  in  the  cornea,  near  the  mem- 
brane of  Descemet,  inflammatory  proliferation  and  fatty  degeneration  of 
the  epithelial  cells,  lining  the  posterior  portion  of  the  cornea,  may  occur. 
They  are  thrown  off,  and,  mixing  with  the  aqueous  humour,  render 
this  turbid,  and  if  these  deposits  are  considerable  in  quantity,  they 
may  fall  down  to  the  bottom  of  the  anterior  chamber  and  thus  produce 
an  hypopyon.  It  has  been  also  supposed  that  the  latter  is  often  due 
to  a  transudation  of  some  of  the  contents  of  the  deep-seated  abscess 
into  the  aqueoiis  humoui'.f  Weber,  however,  asserts  that  he  has  never 
met  wath  an  instance  in  which  the  communication  between  the  abscess 
and  the  anterior  chamber  could  not  be  distinctly  proved  by  means  of 
probing.  I  have,  however,  met  with  cases  of  abscess  in  the  middle  por- 
tion of  the  cornea,  which  have  been  accompanied  by  an  infiltration 

*  "  A.  f.  O.,"  viii,  1,  322. 
t  Roser,  ibid.,  ii,  2,  151. 

H   2 


100  DISEASES   OF   THE  CORNEA. 

situated  at  the  membrane  of  Descemet,  and  an  hypopyon  evidently 
produced  by  the  latter  (for  there  was  no  ii-itis),  and  in  which  I  have 
failed,  on  the  most  careful  examination  by  the  oblique  illumination,  to 
trace  any  communication  between  the  abscess  and  the  posterior  in- 
filtration. 

Inflammatory  suppurative  corneitis  is  raet  with  in  severe  and 
aggravated  cases  of  phlyctenular  corneitis,  and  also  in  severe  cases  of 
purulent,  granular,  and  diphtheritic  ophthalmia.  It  is  very  frequently 
caused  by  mechanical  and  cheraical  injuries,  such  as  the  lodgment  of 
chips  of  steel,  a  bit  of  wheat  ear,  etc.,  in  the  substance  of  the  cornea, 
which  perhaps  remain  there  undiscovered.  This  is  especially  the  case 
in  old  or  very  feeble  persons.  It  may  also  follow  operations  upon  the 
eye,  more  particularly  those  for  cataract. 

In  the  milder  cases  of  inflammatory  suppurative  corneitis,  atropine 
should  be  applied  three  or  four  times  daily,  and  the  compress  bandage 
employed.  If  there  is  much  irritability  and  ciliary  neuralgia,  and  if  the 
eye  is  very  painful  to  the  touch,  two  or  three  leeches  should  be  applied 
to  the  temple.  Subcutaneous  injections  of  morphia  may  also  be  em- 
ployed with  great  advantage.  If  the  abscess  resists  all  treatment,  great 
benefit  is  often  derived  fi*om  slightly  opening  it  with  the  point  of  an 
extraction  knife.  But  if  it  is  deep  seated,  and  thi'eatens  to  per- 
forate the  cornea,  paracentesis  should  be  performed  by  passing  a  fine 
needle  into  the  anterior  chamber  through  the  bottom  of  the  abscess. 
If  a  considerable  hypopyon  exists  paracentesis  should  also  be  per- 
formed, but  with  a  broad  needle,  the  object  of  this  operation  being  not 
so  much  to  remove  the  lymph  from  the  anterior  chamber  as  to 
diminish  the  intra-ocular  pressui'e,  and  thus  to  arrest  the  progress  of  the 
disease,  to  hasten  the  absorption  of  the  infiltration,  and  facilitate  the 
regeneration  of  the  corneal  tissue.  This  operation  may  have  to  be  re- 
peated several  times  (vide  treatment  of  ulcers  of  the  cornea  by  paracen- 
tesis). In  order  to  diminish  the  intra-ocular  pressure  still  more  com- 
pletely, and  more  efiectually  to  subdue  the  inflammation,  it  may  be 
very  advisable  to  perform  iridectomy  in  cases  in  which  suppurative 
corneitis  is  extensive,  threatens  perforation,  and  is  accompanied  by 
hypopyon.  This  is  more  especially  the  case  if  the  abscess  is  deep,  and 
situated  in  the  centre  of  the  cornea,  for  even  if  it  should  not  perforate, 
it  will  leave  a  dense  leucoma,  which  will  subseqiiently  necessitate  the 
formation  of  an  artificial  pupil.  It  is,  therefore,  much  wiser  to  make  an 
iridectomy  at  once,  as  this  will  exert  a  beneficial  influence  upon  the 
course  of  the  disease,  and  leave  an  artificial  pupil  opposite  a  clear 
portion  of  the  cornea. 


NON-IMFLAMMATORY   SUPPURATIVE   CORNEITIS.  101 

5.— NON-INFLAMMATORY  SUPPURATIVE  CORNEITIS. 

In  this  disease  there  is  generally  a  very  marked  absence  of  all  the 
usual  symptoms  of  irritation  and  inflammation.  There  is  no  photo- 
phobia, lachrymation,  or  pain,  and  the  eye  appears,  in  fact,  abnormally 
insensible  to  external  irritation  (bright  light,  etc.)  It  may,  however, 
supervene  upon  a  circumscribed  infiltration  of  the  cornea,  accompanied 
Ijy  severe  symptoms  of  irritation  and  intense  ciliary  neuralgia.  These 
symptoms  suddenly  yield,  and  the  abscess  shows  a  tendency  to 
necrosis,  extending  quickly  in  circumference  and  depth.  There  is 
formed  very  rapidly,  often  in  the  coui^se  of  a  few  hours,  in  the  centre  of 
the  cornea,  a  small  yellow  spot,  which  is  sharply  defined  against  the 
clear  and  transparent  cornea,  and  is  not  surrounded  by  an  opaque  grey 
zone,  as  is  the  case  with  the  inflammatory  infiltration.  Indeed,  the 
adjoining  portion  of  cornea  may  even  appear  abnormally  lustrous, 
which  is  probably  due  to  serous  infiltration.  The  yellow  colour  is 
also  more  deep  and  pronounced  than  in  the  inflammatory  infiltration. 
The  disease  rapidly  extends  in  cii"cum.ference,  and  consecutive  yellow 
layers  are  formed  around  the  original  infiltration.  The  tissue  of  the 
cornea  becomes  quickly  broken  down,  undergoes  fatty  degeneration, 
and  pus  cells  are  formed  in  large  quantity,  and  the  abscess  soon  gains  a 
considerable  extent,  both  on  the  surface  and  in  depth,  reaching, 
perhaps,  nearly  to  the  membrane  of  Descemet.  When  the  suppuration 
has  attained  a  certain  depth,  the  epithelial  cells  lining  the  membrane 
of  Descemet  undergo  inflammatory  proliferation,  and  being  thrown  off" 
mix  with  the  aqueous  humour,  rendering  this  turbid,  and  perhaps 
sinking  down  in  the  anterior  chamber  in  the  form  of  an  hypopyon. 
The  iris  becomes  swollen,  hypera3mic,  and  of  a  yellowish  red  colour, 
due  probably  in  part  to  the  hypera^mia,  and  in  part  to  a  pm-ulcnt 
infiltration  of  its  tissue.  There  are  generally  no  adhesions  between  the 
edge  of  the  pupil  and  the  capsule  of  the  lens.  The  tendency  of  this 
non-inflammatory  form  of  suppurative  corneitis  is  to  extend  rather  in 
circumference  than  in  depth,  so  that  it  leads  to  very  considerable 
opacity  or  even  extensive  suppuration  of  the  cornea,  with  all  its 
dangerous  consequences. 

When  the  process  of  reparation  sets  in,  we  find  that  the  yellow  and 
sharply  defined  infiltration  becomes  surrounded  by  a  greyish  zone,  and 
that  there  is  at  the  same  time  an  increase  in  the  vascularity  of  the  eye. 
Much  of  the  danger  is  now  past,  for  the  disease  assumes  more  of  the 
character  of  inflammatory  suppurative  corneitis,  and  shows  a  tendency 
to  become  limited,  and  there  is,  consequently,  much  less  fear  of  purulent 
necrosis  and  sloughing  of  the  cornea.  Gradually  the  yellow  colour  is 
changed  to  a  whitish  grey,  the  purulent  infiltration  breaks  down  and  is 


102  DISEASES   OF   THE   CORNEA. 

absorbed,  and  the  corneal  tissue  is  regenerated.  It  may,  after  a  time, 
even  regain  its  normal  transparency,  especially  in  children,  and  if  the 
infiltration  was  but  small  and  superficial.  Otherwise,  a  more  or  less 
dense  opacity  is  left  behind,  which,  if  it  be  situated  in  the  centre,  may 
cause  great  impairment  of  vision.  But  if  a  sufficient  portion  of  the 
margin  of  the  cornea  is  transparent  and  of  normal  curvature,  excel- 
lent sight  may  often  be  restored  by  the  formation  of  an  artificial  pupil. 
But,  unfortunately,  so  favourable  a  result  is  not  always  obtained  in 
severe  and  extensive  suppurative  corneitis.  Perforation  of  the  cornea 
but  too  frequently  takes  place,  followed  by  anterior  synechia  or 
staphyloma,  or  the  inflammation  extends  to  the  other  tissues  of  the  eye- 
ball, and  panophthalmitis  occurs,  ending  in  atrophy  of  the  globe. 

Inflammatory  suppurative  corneitis  occurs  frequently  in  very  aged 
and  feeble  persons,  raore  especially  after  operations  involving  the 
cornea  (such  as  those  for  cataract,  especially  the  flap  operation),  or 
after  injuries  to  the  cornea  from  foreign  bodies  striking  it  or  becoming 
lodged  upon  it.  Thus,  it  is  not  unfrequently  met  with  amongst  aged 
country  people  if  a  bit  of  wheat  ear,  or,  perhaps  the  wing  of  an  insect, 
becomes  imbedded  in  the  cornea  and  is  not  removed  at  once.  I  have 
seen  it  produced  sometimes  by  concussion  from  a  simple  blow  against 
the  eye  by  a  bit  of  wood,  the  bough  of  a  tree,  etc.,  without  any 
Avound  of  the  coi'nea.  It  sometimes  occiirs  amongst  young  children, 
and  may  then  assume  even  an  epidemic  character  (Von  Graefe,  Roser). 
It  may  also  supervene  upon  severe  constitutional  diseases,  which  have 
greatly  weakened  the  general  health,  such  as  typhus  fever,  cholera, 
encephalitis,  diabetes,  etc. 

It  may  likewise  follow  paralysis  of  the  fifth  nerve,  and  is  then  termed 
neuro-paralytic  ophthalmia.  The  aflection  of  the  cornea  is  generally 
chronic,  and  occurs  some  time  after  the  paralysis.  If  the  latter  is  partial, 
the  cornea  is  but  rarely  affected,  and  then  only  partially,  and  not  to  a 
severe  extent.  The  eye  loses  its  sensibility,  so  that  when  irritants 
(e.g.,  astringent  collyria)  are  applied  to  it,  they  excite  redness,  but  no 
feeling  of  pain  or  discomfort,  indeed  their  presence  is  unfelt.  The 
cornea  then  becomes  opaque,  ulcers  may  form,  and  suppuration  may 
take  place,  leading  perhaps  to  perforation,  hypopyon,  etc.,  and 
the  inflammation  may  even  extend  to  the  iris.  The  epithelium  of 
the  cornea  and  conjunctiva  becomes  rough  and  dessicated,  so  that  a 
certain  degree  of  xerophthalmia  is  produced.  One  very  interesting 
fact  is,  that  paralysis  of  the  fifth  nerve  always  produces  a  diminution  of 
the  intra-ocular  tension,  and  this  is  a  point  of  the  utmost  importance 
with  regard  to  the  whole  question  of  glaucoma  and  increased  intra- 
ocular tension. 

The  affection  of  the  cornea  which  may  ensue  upon  pai^alysis  of  the 
fifth  nerve  is  apparently  not  due  to  mal-nutrition   of  the   part,   but 


NOX-ixFLA:\iiMATORY  suppurati\t:  corneitis.  103 

simply  to  nieeliauical  injuries,  caused  by  the  action  of  external 
irritants  (dust,  sand,  etc.)  to  which  the  eye  is  exposed,  and  whose 
presence,  on  account  of  its  insensibility,  it  does  not  resent  or  feel. 
That  this  is  so,  has  been  uncontroverfcibly  proved  by  the  experiments  of 
Snellen  and  others.  Snellen  divided  the  fifth  nerve  in  rabbits,  and 
sewed  their  ears  over  the  eyes,  so  as  to  protect  the  latter  from  all 
external  irritants,  and  he  found  that  when  this  was  done  the  cornea 
did  not  become  affected,  whereas,  it  began  to  become  opaque  the  very 
day  after  the  eye  was  left  uncovei^ed.  More  lately  he  has  reported*  a 
very  interesting  case,  which  fully  bears  out  this  view.  A  man,  36  years 
of  age,  was  afiected  with  complete  paralysis  of  the  left  fifth  nerve, 
together  with  paralysis  of  the  sixth  nerve  of  the  same  side.  In  conse- 
quence of  the  latter,  there  existed  a  convergent  squint  of  the  left  eye, 
and  on  the  outer  side  of  the  cornea  there  was  a  superficial  ulcer, 
surrounded  by  a  tolerably  broad  grey  zone.  The  eye  was  quite 
insensible,  and  the  acuteness  of  vision  diminished  to  -oVo)  ^^^  its 
tension  was  much  decreased.  In  order  to  ascertain  with  certainty 
whether  the  affection  of  the  cornea  was  due  to  mal-nutrition  of  the  eye, 
or  to  its  exposure  to  external  irritants,  Snellen  fastened,  by  means  of 
strips  of  plaster,  a  stenopaic  shell  over  the  eye,  in  order  to  protect  it. 
A  small  central  aperture  was  left  for  the  patient  to  see  through,  so 
that  he  might  ascertain  whether  the  shell  retained  its  proper  position, 
for  from  the  want  of  sensibility  of  the  eye,  he  could  not  determine  it  other- 
wise. The  shell  was  removed  twice  a  day  in  order  that  the  eye  might 
be  washed  and  cleansed.  The  improvement  in  the  condition  of  the 
cornea  and  the  sight  was  very  marked,  for  within  two  days  the  vision 
=  1^9.,  and  the  cornea  cleared  so  rapidly,  that  in  eight  days  after  the 
application  of  the  shell  the  acuteness  of  vision  was  normal,  viz.,  =  -|^. 
Only  a  small  opacity  remained  at  the  outer  side  of  the  cornea,  but 
the  loss  of  sensibility  and  the  diminished  tension  continued.  The 
application  of  turpentine  and  nitrate  of  silver  produced  ,the  same 
symptoms  of  congestion  as  in  a  normal  eye,  wdthout,  however,  being 
felt  by  the  patient.  The  stenopaic  cup  was  left  off,  and  the  eye 
exposed ;  within  two  days  the  eye  became  again  more  infiamed,  and 
the  vision  became  diminished  to  ^wo-  ^^  shortly  regained  its  normal 
standard  after  the  re-application  of  the  shell. 

Meissnerf  is,  however,  of  opinion  that  this  tendency  to  inflam- 
mation of  the  cornea  is  not  altogether  due  to  the  loss  of  sensibility, 
for  he  has  observed  three  cases  in  which  no  corneitis  ensued  after 
division  of  the  fifth  nerve,  although  the  eye  was  quite  insenBible,  and 
not  guarded  against  external  irritants.  On  examination,  it  was  found 
that  in   all  these  instances   the  innermost  portion  of  the   nerve  had 

*  "  Jaarlijkscli  Verslag,  etc.,"  1863. 

t  Henle  and  Pfeuffer's  "  Ztschr,"  (3),  xxix,  9G. 


104  DISEASES   OF   THE  GORNEA. 

escaped  division.  He,  therefore,  considers  it  probable  that  the  fibres  of 
this  portion  of  the  nerve  render  the  eye  more  able  to  resist  the  effect  of 
external  irritants,  etc.  This  supposition  is  strengthened  by  another 
case,  in  which  Meissner  incompletely  divided  the  fifth  nerve  in  a  rabbit, 
and  although  the  sensibility  of  the  eye  was  not  impaired,  the  inflamma- 
tion of  the  cornea  ensued  in  the  customary  manner.  On  examination, 
it  was  found  that  only  the  median  (innermost)  portion  of  the  nerve 
had  been  divided.  Scliiff  *  has  repeated  these  experiments  with  exactly 
the  same  results. 

The  very  dangerous  character  of  non-inflammatory  suppurative 
corneitis  is  chiefly  due  to  the  rapidity  with  which  the  infiltration  ex- 
tends, more  especially  in  circumference,  and  to  the  great  tendency  to 
purulent  necrosis  of  the  corneal  tissue,  which  leads  but  too  frequently 
to  very  extensive  suppuration  of  the  cornea,  or  even  to  purulent  dis- 
organization of  the  eyeball.  This  disease  proves  especially  disastrous 
if  it  be  treated  by  the  ordinary  antiphlogistics,  e.g.,  cold  compresses, 
leeches,  etc.,  more  particularly  in  severe  cases.  Thus  Von  Graefe 
found,  that  when  he  pursued  this  mode  of  treatment  he  lost  about  three- 
fourths  of  the  severer  cases.  Whereas,  his  success  was  very  marked 
as  soon  as  he  substituted  warm  fomentations  and  the  compress  bandage. 
The  object  of  the  warm  fomentations  is  to  excite  a  certain  degree  of 
inflammatory  reaction  and  swelling  in  the  conjunctiva  and  cornea ;  for 
in  the  total  absence  of  these  is  to  be  sought  the  chief  danger  of  the 
disease.  They  also  hasten  the  Hmitation  of  the  suppuration,  expedite 
the  absorption  of  the  infiltration,  and  favour  the  process  of  reparation. 
After  their  application  the  eye  becomes  more  injected,  and  this  is  ac- 
companied by  inflammatory  swelling  of  the  conjunctiva.  The  vascu- 
larity also  extends  more  or  less  on  to  the  cornea.  The  infiltration  is  no 
longer  sharply  defined  against  the  transparent  cornea,  but  a  grey  halo 
appears  around  it,  and  this  portion  of  the  cornea  is  somewhat  swollen, 
and  the  line  of  demarcation  soon  becomes  well  marked.  If  an  hypo- 
pyon exists,  and  is  not  very  considerable  in  extent,  we  often  find  that 
it  becomes  rapidly  absorbed  after  the  use  of  warm  fomentations.  Von 
Graefef  generally  uses  warm  camomile  fomentations,  varying  in  tem- 
perature from  about  90°  to  104°  of  Fahrenheit,  according  to  the  condi- 
tion of  the  eye.  The  less  the  symptoms  of  inflammatory  irritation,  the 
higher  should  the  temperature  be.  They  should  be  changed  every  five 
minutes,  and  their  use  suspended  for  one  quarter  in  every  hour.  The 
temperature  should  be  lowered  and  the  fomentations  changed  less  fre- 
quently, or  a  longer  interval  be  allowed  to  elapse  between  their  appli- 
cation, as  soon  as  the  zone  of  demarcation  and  the  inflammatory  swelling 

*  Henle  and  Pfeuffer's  "  Ztschr,"  (3),  xxix,  p.  217. 

t  "  A.  f.  O.,"  vi,  2,  133.  Vide  also  the  author's  abstract  of  this  paper  in  "  Koy. 
Lond.  Ophth.  Hosp.  Reports,"  vol.  iii,  128. 


NON-INFLAMMATORY   SUPPURATIVE   CORNEITIS.  105 

make  their  appearance,  and  tlie  necrosed  portions  of  cornea  begin  to  be 
thrown  off.  If  these  points  are  not  attended  to,  we  may  set  np  too 
great  an  inflammatory  reaction,  so  that  it  may  even  become  necessary 
to  check  it  by  antiphlogistic  applications  (cold  compresses,  leeches, 
etc.).  Samisch,*  who  has  extensively  studied  the  eifect  of  warm  fo- 
mentations, advocates  their  continuation  for  a  somewhat  longer  period 
in  certain  cases,  in  order  to  promote  the  exfoliation  of  the  necrosed 
portions,  and  to  expedite  the  absorption  of  the  morbid  products.  Their 
effect  must  then,  however,  be  closely  watched,  in  order  that  too  much 
inflammation  is  not  set  up.  Indeed,  the  employment  of  warm  fomen- 
tations requii'es  gi'eat  circumspection  and  attention,  and  cannot  be 
entrusted  to  a  stupid  or  careless  nurse,  for  if  they  are  applied  too  hot, 
changed  too  frequently,  or  continued  too  long,  they  may  produce  an 
excess  of  inflammation ;  or  if,  on  the  other  hand,  they  are  permitted 
to  get  cold,  they  are  even  still  more  inju.rious,  by  diminishing  the 
vitaHty  of  the  part,  and  thus  increasing  the  tendency  to  necrosis. 
Where  I  cannot  rely  upon  the  care  and  attention  of  the  nurse,  I  am  in 
the  habit  of  ordering  the  occasional  use  of  warm  poppy  or  camomile 
fomentations  at  stated  periods.  For  instance,  three  or  four  times  a  day 
for  the  period  of  half  an  hour  ;  the  fomentations  being  changed  every 
five  minutes  during  that  time.  In  this  way  considerable  benefit  may 
be  derived  from  their  use,  without  incurring  any  risk. 

Warm  fomentations  are  indicated  in  all  forms  of  non-inflammatory 
suppurative  corneitis,  whether  of  spontaneous  origin,  or  caused  by  in- 
juries to  the  eye  or  operations  (especially  those  for  the  removal  of 
cataract).  They  may  also  be  necessary  in  cases  of  inflammatory  sup- 
purative corneitis  if  the  symptoms  of  inflammation  have  sunk  below  a 
certain  point. 

Great  advantage  is  also  experienced  from  the  use  of  a  firm  com- 
press or  the  "pressure  bandage"  (vide  p.  13),  for  this  is  of  much 
service  in  limiting  the  extent  of  the  suppuration  and  hastening  the 
foi-mation  of  the  zone  of  demarcation.  Its  application  should  alternate 
with  the  warm  fomentations. t  Even  a  certain  degree  of  ii-itis  does  not 
contra-indicate  its  use.  According  to  Von  Graefe,  it  is  not,  however, 
applicable  in  those  cases  in  which  the  purulent  necrosis  occurs  rapidly, 
after  the  sudden  cessation  of  severe  symptoms  of  limitation  and  ciliary 
neuralgia,  with  which  the  disease  was  ushered  in.  After  the  pain  had 
been  alienated  by  subcutaneous  injection  of  morphia,  and  warm  fomen- 
tations had  been  applied.  Von  Graefe  then  found  much  benefit  from  the 
use  of  chlorine  water.  J  If  there  is  any  iritis  and  the  aqueous  humour  is 
turbid,  \\ith  or  without  the  presence  of  hypopyon,  it  is  most  advisable 

*  "  Klinische  BeobacUungen  von  Pagenstecher  and  Samiscli,"  2,  102 ;  18G2. 
t  "A.  f.  0.,"  Tol.  ix,  2,  151. 
J  Ibid,,  Tol.  X,  2,  205. 


106  DISEASES   OF   THE   CORNEA. 

to  perform  iridectomy  without  delay.  This  will  generally  at  once  cut 
short  the  progress  of  the  disease  and  stop  the  extension  of  the  sup- 
puration. But  if  it  is  found  that  this  improvement  is  but  temporary, 
and  lasts  but  for  a  feAV  days,  Von  Graefe  advises  that  the  chlorine  water 
should  be  again  applied.  He  has  done  this  even  within  thirty  hours 
after  the  operation,  if  fresh  crescentic  infiltrations  showed  themselves 
around  the  original  abscess,  and  he  found  that  their  extension  was 
decidedly  and  markedly  checked  by  this  remedy. 

In  the  neuro-paralytic  form  of  comeitis,  a  light  bandage  should  be 
applied  over  the  eye  so  as  to  protect  it  against  all  external  irritants. 
It  should  be  removed  two  or  three  times  daily,  and  the  eye  washed 
and  cleansed.  If  the  case  be  seen  sufficiently  early  and  before  any 
considerable  mischief  has  been  done,  this  remedy  will  generally  suffice 
rapidly  to  cure  the  affection  of  the  cornea. 

Atropine  drops  should  always  be  applied,  as  they  not  only  act  as 
an  anocfyneTlbut  also  diminish  the  intra-ocular  tension.  They  are  of 
especial  importance  if  there  is  any  iritis. 

If  perforation  of  the  cornea  appears  imminent,  and  the  ulcer  is  not 
of  considerable  size,  a  paracentesis  should  be  made  with  a  fine  needle 
through  the  bottom  of  the  ulcer,  so  as  to  allow  the  aqueous  humour 
to  flow  ofi"  very  slowly.  This  wOl  diminish  the  intra-ocular  tension 
and  facilitate  the  absorption  of  the  infiltration,  and  the  filling  up  of  the 
ulcer.  But  if  the  infiltration  or  ulcer  is  deep  seated,  of  considerable 
extent,  and  shows  a  tendency  to  increase  still  more,  or  to  perforate  the 
cornea,  paracentesis  should  be  at  once  performed.  It  is  also  indicated 
if  a  certaiif  degree  of  hypopyon  is  present,  mth  or  without  iritis.  It 
has  been  already  stated  that  our  object  in  tapping  the  anterior  chamber 
is  less  to  remove  the  lymph  than  to  diminish  the  intra-ocular  pressure, 
and  thus  to  stop  the  progress  of  the  disease,  hasten  the  absorption  of 
the  morbid  products,  and  facilitate  the  regeneration  of  the  corneal 
tissue.  The  incision  is  to  be  made  with  a  broad  needle  in  the  cornea 
near  its  lower  edge,  and  the  aqueous  humour  should  be  allowed  to  flow 
off"  very  slowly  indeed.  It  may  be  necessaiy  to  repeat  the  operation 
several  times,  or,  in  order  that  its  efiect  may  be  more  lasting,  the  little 
wound  may  "be  kept  patent  by  the  occasional  insertion  of  a  small  probe 
once  or  twice  a  day. 

But  if  the  hy|5opyon  is  considerable  in  size,  occupying  perhaps  one- 
third  or  one-half  of  the  anterior  chamber,  if  there  is  much  iritis,  or  if 
the  abscess  in  the  cornea  extends  very  deeply,  and  threatens  to  oaase 
an  extensive  perforation,  it  is  of  great  importance  that  an  iridectomy 
should  be  made  without  loss  of  time.  For  the  intra-ocular  tension 
will  be  thus  more  completely  diminished  and  for  a  longer  period,  than 
by  the  paracentesis.  We  generally  find  that  the  iridectomy  exerts  a 
most  beneficial  influence  upon  the  suppuration  of  tliecornea,  and  also 


NOX-IXFLA:\DrATORY   SUPPURATIVE   CORNEITIS.  107 

as  an  autiplilog-istic  upon  the  inflammation  of  the  iris.  The  pi'Ogress 
of  the  suppm-ation,  both  in  circiimforence  and  depth,  is  arrested,  the 
deeper  layers  of  the  cornea  do  not  become  necrosed,  and  the  absorption 
of  morbid  products,  and  the  process  of  repair  are  hastened.  Indeed, 
I  think  that  an  iridectomy  should  generally  be  preferred  to  a  paracen- 
tesis if  the  disease  be  at  all  severe  and  threatening  perforation,  more 
especially  if  the  abscess  or  ulcer  be  of  considerable  size  and  situated  in 
the  centre  of  the  cornea,  for  then  it  will  leave  a  dense  opacity  behind  it, 
and,  after  all,  necessitate  the  formation  of  an  artificial  pupil. 

If  there  is  a  considerable  hypopyon,  the  iridectomy  should  be  made 
downwards,  or  downwai-ds  and  inwards,  in  order  that  the  lymph  may 
escape  with  the  aqueous  humour  through  the  large  incision.  If  it  does 
not  do  so  readily,  it  is  better  to  leave  some  of  it  in  the  anterior  chamber 
than  to  pull  and  drag  upon  it  in  the  endeavour  to  remove  it,  for  this 
may  set  up  great  irritation.  I  think  that  this  is  to  be  preferred  to  makino- 
the  iridectomy  upwards  and  then  endeavouring  to  remove  the  lymph  by 
a  pair  of  forceps,  for  this  will  drag  upon  the  lower  portion  of  the  iris, 
and  may  produce  much  irritation  and  increase  the  inflammation. 

Weber  strongly  recommends  that  the  paracentesis  should  be  made 
with  ^  broad  needle  through  the  bottom  of  the  abscess,  so  that  it  may 
be  split  across ;  the  gush  of  aqueous  humour  through  the  incision  will 
carry  with  it  more  or  less  of  the  contents  of  the  abscess,  and  thus 
cleanse  it  and  favour  its  filling  up. 

In  the  non-inflammatory  suppurative  corneitis  it  is  of  great  im- 
portance to  keep  up  the  patient's  general  health.  As  this  afl'ection  is 
most  prone  to  occur  in  delicate,  weakly  children  and  in  old  and  feeble 
individuals,  tonics  and  difiusible  stimulants  should  be  freely  adminis- 
tered, and  the  patient  be  placed  upon  a  generous  diet,  with  wine  or  malt 
liquor.  I  have  been  occasionally  obliged  to  treat  cases  of  this  kind  as 
hospital  out-patients,  and  have  sometimes  succeeded  in  obtaining  very 
successful  results,  even  although  the  suppuration  was  already  extensive 
and  accompanied  by  some  hypopyon  and  iritis.  In  such  cases  I  have 
always  applied  atropine,  warm  poppy  fomentations  three  or  four  times 
daily,  and  a  compress  bandage,  and  performed  paracentesis  (perhaps 
repeatedly)  when  the  hypopyon  had  reached  to  more  than  one-foui'th  of 
the  anterior  chamber.  I  have  at  the  same  time  prescribed  full  doses  of 
quinine  and  steel,  combined  perhaps  with  ammonia  or  mixed  acids,  a 
good  diet,  and  stimulants. 

But  only  absolute  necessity  should  induce  us  to  treat  such  cases  as 
out-patients,  as  the  disease  is  of  the  gravest  nature,  and  demands  the 
frequent  attention  of  the  surgeon  and  the  constant  care  of  a  good 
nurse. 


108  DISEASES   OF   THE   CORNEA. 

6.— ULCERS  OF  THE  CORNEA.  • 

Ulcers  of  tlie  cornea  vary  mucli  in  importance  and  clanger  accord- 
ing to  their  extent  and  tlieir  situation ;  in  some  cases  their  course  is 
acute  and  rapid,  in  others  very  chronic  and  protracted,  obstinately 
defying  almost  every  remedy.  The  superficial  are  less  important  and 
dangerous  than  the  deep-seated  ulcers.  In  the  former,  we  should  not 
include  mere  abrasions  of  the  epithelium  such  as  may  occur  after  slight 
injuiues  from  foreign  bodies,  or  from  the  bursting  of  the  vesicle  in 
phlyctenular  corneitis.  The  term  ulcer  should,  I  think,  be  confined 
to  cases  in  which  there  is  a  breaking  down  and  elimination  of  the 
affected  corneal  tissue,  so  that  there  is  a  distinct  loss  of  substance. 

When  sjDeaking  of  phlyctenuliB,  and  the  inflammatory  infiltrations  of 
the  cornea,  it  was  mentioned  that  their  contents  often  break  down, 
soften,  and  are  thrown  ofi",  giving  rise  to  an  ulcer,  which  may  either 
remain  superficial  or  extend  somewhat  deejaly  into  the  corneal  tissue. 
But  the  tendency  to  ulceration  may  also  show  itself  from  the  outset.  Then 
there  is  noticed,  near  the  centre  or  the  margin  of  the  cornea,  a  small 
opacity,  the  edges  of  which  are  somewhat  irregular,  swollen,  and  of  a 
grey  colour,  which  shades  ofi"  to  a  lighter  tint  towards  the  centre,  so 
that  the  latter  may  even  seem  quite  transparent.  The  ulcer,  whose 
epithelial  covering  is  lost,  is  surrounded  by  a  zone  of  grey  and  some- 
what swollen  cornea ;  it  gradually  assumes  a  more  yellow  tint,  and 
extends  in  depth  and  circumference,  its  contents  breaking  down  and 
being  cast  off",  so  that  it  may  reach  a  considerable  extent  before  its  pro- 
gress can  be  stopped.  It  is  often  accompanied  by  severe  symptoms  of 
irritation,  great  photophobia,  lachrymation,  and  ciliary  neuralgia.  When 
the  process  of  reparation  sets  in  we  notice  that  the  epithelial  layer  is 
gradually  formed,  this  reparation  commencing  from  the  periphery.  The 
ulcer  assumes  a  greyer  tint  and  is  gradually  filled  up  by  new  tissue, 
which  may  resemble  very  greatly  the  normal  corneal  tissue,  although 
the  intercellular  substance  is  apt  to  be  not  quite  transparent,  thus 
giving  rise  to  a  certain  amount  of  opacity.  Sometimes  the  process  of 
repair  is  extremely  slow  and  many  months  elapse  before  the  nicer  is 
healed.  As  soon  as  the  layer  of  epithelium  is  regenerated  the  symptoms 
of  irritation,  more  especially  the  pain  and  photophobia,  rapidly  subside. 
Blood-vessels  (both  venous  and  arterial)  appear  upon  the  coi'nea  and 
run  towards  the  ulcer,  hastening  the  process  of  reparation  and  absorp- 
tion, and  dwindling  down  and  disappearing  when  their  task  is  done. 
Sometimes  the  reparative  process  is  incomplete,  and  a  more  or  less  deep 
opaque  depression  or  facet  of  a  somewhat  cicatricial  appearance  remains 
behind. 

We  sometimes  meet  with  a  peculiar  form  of  funnel-shaped  ulcer, 
which  shows  a  very  marked  tendency  to  extend  in  depth  and  perforate 


ULCERS  OF  THE  CORNEA.  109 

the  cornea,  obstinately  and  persistently  resisting  all  and  every  kind 
of  treatment  until  perforation  has  taken  place,  when  it  at  once  begins 
to  heal. 

Another  and  very  dangerous  form  is  the  crescentic  ulcer,  which 
commences  near  the  edge  of  the  cornea,  and  looks  as  if  a  little  portion 
had  been  chipped  out  with  the  finger-nail.  It  shows  a  great  tendency 
to  extend  more  and  more  round  the  edge  of  the  cornea  like  a  trench 
(in  which  the  cornea  is  much  thinned),  until  it  may  even  encircle  the 
whole  cornea.  The  vitality  of  the  central  portion  is  generally  greatly 
impaired,  and  it  becomes  more  and  more  opaque  and  shrivels  up  until 
it  may  look  like  a  yellow,  dry,  friable  or  cheesy  substance,  portions  of 
the  surface  of  which  may  be  thrown  off",  or  it  may  give  way  and  a 
very  extensive  rupture  of  the  conica  take  place.  This  crescentic  ulcer 
is  extremely  dangerous  and  intractable,  resisting  often  most  obstinately 
every  form  of  treatment.  In  some  cases  great  advantage  has  been 
dei'ived  from  syndectomy,  cither  partial  if  the  ulcer  was  but  of  slight 
extent,  or  complete  if  a  considerable  portion  of  the  cornea  had  become 
involved.  In  other  cases  1  have,  however,  seen  it  do  but  very  little 
good.  Iridectomy  has  also  been  sometimes  found  of  benefit,  and  should 
be  preferred  to  paracentesis.  The  patient  should  be  placed  upon  a 
very  nutritious  and  generous  diet,  and  tonics,  together  perhaps  with 
mixed  acids,  should  be  administered. 

Whilst  these  different  forms  of  corneal  ulcer  are  always  accom- 
panied by  more  or  less  irritation  and  inflammation,  there  are  also  some 
forms  in  which  the  inflammatory  symjDtoms  are  almost  entirely  absent ; 
they,  indeed,  in  their  character  and  course  may  closely  resemble  the 
non-inflammatory  suppurative  corneitis.  We  notice  that  the  ulcer  is 
white  in  colour  and  clearly  defined  against  the  transparent  cornea,  and 
not  suiTounded  by  a  grey  swollen  zone  of  demarcation.  It  is  accom- 
panied by  very  little,  if  indeed  any,  photophobia,  lachrymation,  redness , 
or  pain;  there  is  also  more  tendency  to  necrosis,  and  extension  in  cir- 
cumference than  in  the  other  forms. 

One  peculiar  and  very  dangerous  kind  of  non- inflammatory  or 
indolent  ulcer  is  that  which  is  often  met  with  in  very  aged  and  decrepid 
individuals,  and  is  generally  accompanied  by  hypopyon.  In  character 
it  closely  resembles  the  non-inflammatory  suppurative  corneitis,  in  fact 
the  latter  very  frequently  passes  over  into  this  form  of  ulcer.  Like  it, 
it  commences  with  a  small  greyish- white  spot,  perhaps  in  the  centre 
of  the  cornea,  which  soon  passes  over  into  an  ulcer  and  extends  very 
rapidly  in  circumference,  the  affected  tissue  breaking  down  and  being- 
cast  off"  until  a  large  superficial  sloughing  ulcer  is  the  result.  When 
it  has  reached  a  certain  depth  it  very  frequently  becomes  complicated 
with  hypopyon,  which  may  be  due  to  iritis,  to  inflammation  of  the 
posterior  layers  of  the  cornea  and  proliferation  of  the  epithelial  cells, 


110  DISEASES  OF   THE   CORNEA. 

or  to  perforation  of  the  ulcer  and  a  discliarge  of  its  contents  into  the 
anterior  chamber.  There  is  a  marked  absence  of  all  inflammatory- 
symptoms,  and  in  this  consists  its  chief  danger,  as  it  leads  to  rapid 
and  extensive  sloughing  of  the  cornea. 

Sometimes  we  may  observe  a  peculiar  transparent  ulcer  of  the 
cornea,  in  which  both  the  margins  and  the  bottom  of  the  ulcer  are 
quite  transparent,  and  free  fi'om  any  opaque  halo ;  there  is  also  an 
absence  of  vascularity.  These  ulcers  are  very  intractable  and  may 
persist  for  a  long  time.  They  may,  however,  heal  rapidly  if  a  sufficient 
degree  of  vascularity  can  be  established. 

The  complications  to  which  ulcers  of  the  cornea  may  give  rise  are 
often  very  serious  and  may  even  prove  destructive  to  the  eye.  If  the 
ulcer  is  superficial,  of  but  slight  extent,  and  occurs  in  a  young  healthy 
subject,  it  may  heal  perfectly,  and  finally  leave  hardly  any,  if  indeed 
any,  opacity  behind ;  the  cornea  in  time  regaining  its  normal  trans- 
parency. Indeed,  even  small  perforating  ulcers  which  have  given  rise 
to  anterior  capsular  cataract,  may  gradually  disappear  without  leaving 
almost  any  trace  behind  them.  I  have  not  unfrequently  met  vsdth  cases 
of  central  capsular  cataract  in  old  persons  whose  cornea  was  apparently 
clear,  and  it  was  not  until  it  was  examined  by  a  strong  light  or  with 
the  oblique  illumination,  that  a  small  opacity  of  the  cornea  could  be 
detected  just  opposite  the  centre  of  the  lens  ;  then,  on  enquiiy,  it  was 
perhaps  ascertained  that  the  patient  had  as  a  child  suSered  from  inflam- 
mation of  the  eye. 

When  the  ulcer  has  extended  very  deeply  into  the  cornea  nearly  as 
far  as  the  membrane  of  Descemet,  the  latter  may  yield  before  the  intra- 
ocular pressure  and  bulge  forward,  looking  like  a  small  transparent  vesicle 
at  the  bottom  of  the  ulcer.  This  condition  has  been  termed  hernia  of  the 
cornea  or  "  keratocele."  If  the  membrane  of  Descemet  be  very  tough 
and  elastic  it  may  protrude  even  beyond  the  level  of  the  cornea,  and 
give  rise  to  a  transparent  prominent  vesicle  like  a  tear  drop.  This  gene- 
rally soon  biirsts,  and  gives  rise  to  an  ulcer,  or  a  fistulous  opening 
may  remain,  and  prove  very  intractable ;  but  it  may  exist  for  weeks  or 
even  months,  when  it  gradually  becomes  thicker,  flatter,  more  opaque, 
and  changed  into  a  kind  of  cicatricial  tissue.  It  was  generally  sup- 
posed that  the  walls  of  this  vesicle  consist  only  of  the  membrane  of 
Descemet  pushed  forward  by  the  aqueous  humour,  but  Stellwag  states 
that  they  also  always  include  some  of  the  deepest  layers  of  the  cornea, 
traces  of  which  may  even  be  found  at  the  sides  of  the  vesicle,  and 
sometimes  also  at  the  apex. 

The  chief  danger  of  the  ulcers,  apart  from  the  dense  opacities  wliich 
they  may  leave  behind,  is  to  be  found  in  their  perforating  the  cornea, 
and  the  degTce  of  this  danger  varies  with  the  extent  and  situation  of 
the  perforation. 


ULCERS  OF  THE  CORNEA.  Ill 

If  the  per-foi-ation  is  but  small,  the  iris  will  fall  against  it  when  the 
aqueous  humour  flows  off',  mthout  protruding  through  it ;  plastic 
lymph  will  be  effused  at  the  bottom  of  the  ulcer  and  this  may  at  once 
commence  to  heal,  the  iris  becoming  slightly  glued  against  the  cornea. 
The  aqueous  humoiu"  re-accumulates,  and  if  the  .adhesion  between  the 
iris  and  cornea  is  but  very  slight,  it  will  yield  before  the  pressure  of  the 
aqueous,  and  the  iris  be  liberated  and  fall  back  to  its  normal  plane. 
The  muscular  action  of  the  sphincter  and  dilator  of  the  iris  during  the 
action  of  the  pnpil  will  also  assist  in  breaking  through  the  adhesion, 
but  if  the  latter  is  at  all  considerable  and  firm,  the  rris  will  remain 
adherent  to  the  cornea,  and  a  more  or  less  extensive  anterior  synechia  be 
formed.  If  the  perforation  is  large,  as  it  must  be  if  the  iris  falls  into 
it  and  protrudes  through  it,  this  protrusion  may  gain  a  considerable 
size  by  the  collection  of  aqueous  humour  behind  it,  which  causes  it 
gradually  to  distend  and  bulge  more  and  more.  The  colour  of  the 
prolapse  is  soon  changed  from  black  to  a  dirty,  dusky  grey  tint,  and  its 
base  is  surrounded  by  a  zone  of  opaque  cornea.  The  portion  of  pro- 
truding iris  which  lies  against  the  edges  of  the  ulcer,  generally  becomes 
united  to  the  latter  by  an  effusion  of  plastic  lymph,  the  aqueous  humour 
is  again  retained,  and  the  anterior  chamber  re-established,  with  the 
exception  of  the  portion  in  the  vicinity  of  the  prolapse,  for  here  the  iris 
is  lifted  away  from  the  anterior  surface  of  the  lens,  and  a  more  or  less 
considerable  posterior  chamber  is  formed.  The  pupil  is  distorted  and 
dragged  towards  the  perforation,  and  the  extent  of  this  distortion  varies 
wdth  the  size  and  situation  of  the  prolapse.  If  a  portion  of  the  pupil  is 
included  in  the  prolapse  it  will  be  irregularly  displaced  and  dragged 
towards  the  latter,  and  diminished  in  size  correspondingly  to  the 
am.ount  of  the  pupil  which  is  involved.  Wlien  the  whole  pupil 
is  included  the  iris  will  be  tensely  stretched  towards  the  perforation ; 
if  the  latter  is  considerable  in  size  and  the  aqueous  humoiu'  has  gushed 
forth  wdth  much  force,  the  lens  and  even  some  of  the  vitreous  humour 
may  be  lost.  If  the  prolapse  is  small  and  seen  shortly  after  it  has  taken 
place,  it  may  often  be  replaced  under  judicious  treatment,  and  the  ulcer 
perhaps  heal  without  even  an  anterior  sjTiechia  remaining  behind,  but 
if  it  is  considerable  in  size  the  result  will  be  much  less  favourable,  for 
the  protruding  portion  of  iris,  exposed  to  the  action  of  external  irri- 
tants, e.g.,  the  air,  movements  of  the  lids,  etc.,  becomes  inflamed  and 
covered  by  a  thin  greyish- white  layer  of  exudation,  which  gTadually  be- 
comes thicker  and  more  organized,  and  assumes  a  cicatricial  texture. 
Now,  if  this  cicatricial  covering  and  the  adhesions  of  the  iris  to  the 
edges  of  the  ulcer  are  not  suf&ciently  strong  to  withstand  the  intra- 
ocular pressure,  the  prolapse  Avill  gradually  increase  in  size,  and  the 
surrounding  portions  of  the  cornea  will  also  bulge  more  and  more  until 
an  extensive  staphyloma  may  be  produced.     If  the  cornea  is  perforated 


112  DISEASES   OF   THE   CORNEA. 

at  several  points,  through  which  small  portions  of  iris  protude,  it  is 
termed  "  Staphyloma  racemosum." 

If  the  perforation  is  very  small,  and  situated  at  or  near  the  centre 
of  the  cornea,  capsular  cataract  may  be  produced  in  the  manner  already 
described.  Again,  the  sudden  escape  of  the  aqueous  humour,  and  falling 
forward  of  the  lens,  may  cause  a  rupture  of  the  capsule,  and  thus  give 
rise  to  lenticular  cataract. 

With  regard  to  ihe  treatment  of  ulcers  of  the  cornea  we  must 
be  chiefly  guided  by  the  amount  of  inflammation  which  is  present. 
Whilst  we  endeavour  to  check  an  undue  degree  of  inflammation, 
we  must  be  on  our  guard  not  to  subdue  it  too  much,  as  this  would 
favour  the  tendency  to  necrosis,  and  protract  the  process  of  repa- 
ration. In  the  progressive  stage  of  an  acute  inflammatory  idcer,  the 
patient  should  be  iept  in  a  somewhat  darkened,  but  well  ventilated 
room,  and  be  guarded  against  the  efiects  of  bright  light,  cold  wind 
and  other  external  irritants.  It  may  be  necessary  to  administer  a 
brisk  purgative  and  saline  diuretics,  together  with  a  light,  non-stimu- 
lating diet,  if  there  are  marked  inflammatory  symptoms  and  the  patient 
is  of  a  strong  plethoric  habit.  But  we  must  be  upon  our  guard  not  to 
prescribe  this  kind  of  treatment  in  all  cases,  for  very  frequently  ulcers 
of  the  cornea  occvir  in  persons  of  delicate,  feeble  health,  and  then  it 
would  prove  injudicious  and  injurious,  for  it  would  increase  the  ten- 
dency to  necrosis,  and  retard  the  filling  up  of  the  ulcer.  In  such  cases 
the  patient  should  be  placed  on  tonics,  and  a  very  nutritious  diet. 
When  the  process-  of  repair  has  set  in,  he  should  be  permitted  to  get 
into  the  open  air,  indeed  this  is  especially  indicated  if  the  disease 
shows  a  tendency  to  become  indolent  and  chronic.  Much  benefit  is 
then  experienced  from  out-of-door  exercise,  and  a  residence  in  the 
country  or  at  the  sea- side. 

The  object  of  our  local  treatment  must  be  to  endeavour  to  diminish 
marked  symptoms  of  inflammatory  irritation,  to  stop  the  progress  of 
the  ulcer,  and  to  hasten  its  repair  and  the  absorption  of  the  morbid 
products.  If  there  is  much  injection,  photophobia,  lachrymation,  and 
ciliary  neuralgia,  atropine  should  be  dropped  into  the  eye,  the  compound 
belladonna  ointment  should  be  rubbed  over  the  forehead,  and  perhaps 
a  blister  applied  behind  the  ear.  If  the  pain  in  and  around  the  eye  is 
very  great,  and  especially  if  the  latter  is  very  tender  to  the  touch,  two 
or  three  leeches  should  be  applied  to  the  temple.  Much  relief  will  also 
be  experienced  from  the  subcutaneous  injection  of  morphia.  A  great 
amount  of  mischief  is  but  too  often  caused  by  the  use  of  strong  caustic 
or  astringent  lotions,  during  the  acute  progressive  stage  of  the  ulcera- 
tion. Not  only  do  they  greatly  augment  the  irritation,  but  they  increase 
the  tendency  to  necrosis  and  extension  of  the  ulcer.  It  is  only  in  the 
(ihronic,  torpid  ulcer  which  has  already  become  covered  by  epithelium, 


ULCERS  OF  THE  CORNEA.  113 

that  caustics  are  at  all  applicable,  and  even  then  they  must  be  used  with 
great  caution  and  circumspection.  In  the  chronic,  indolent,  non- inflam- 
matory ulcer  we  must  apply  atropine,  a  compress  bandage,  and  above  all, 
warm  fomentations,  in  order  to  excite  a  certain  degree  of  inflammatory 
swelling ;  or  the  yellow  oxide  of  mercury  ointment  may  be  employed, 
for  this  remedy  hastens  the  process  of  absorjDtion  and  tends  to  prevent 
relapses.  The  patient's  health  must  be  invigorated  by  tonics,  a  generous 
diet,  and  stimulants ;  indeed  the  same  line  of  local  and  general  treat- 
ment must  be  adopted  as  in  the  non-inflammatory  suppurative  corneitis. 
We  must  never  forget  to  apply  a  comjoress  bandage  over  the  eye,  in 
order  not  only  to  guard  it  against  external  irritants,  but  to  support  the 
thinned  ulcerated  portion  of  the  cornea  against  the  intra-ocular  pressure, 
and  to  prevent  the  constant  movements  of  the  eyelids,  which  greatly 
impede  the  formation  of  an  epithelial  covering  over  the  ulcer ;  which, 
as  we  have  seen,  forms  the  commencement  of  the  retrogressive  and 
reparative  stage. 

In  all  ulcers  of  the  cornea,  but  more  especially  in  those  which 
extend  deeply  into  its  substance,  the  process  of  repair  is  greatly 
retarded  by  the  high  amount  of  intra-ocular  pressui'e  which  the  thinned 
portion  of  the  cornea  at  the  bottom  of  the  ulcer  has  to  bear.  In  con- 
sequence of  this,  the  latter  is  very  apt  either  to  give  way  com- 
pletely, and  to  perforate ;  or  else  it  yields  somewhat  before  the  intra- 
ocular pressure,  bulges  forwards,  sloughs,  and  is  partly  throvni  off,  and 
thus  the  process  of  repair  is  much  impeded.  Now  we  possess  three 
principal  means  of  diminishing  the  intra-ocular  pressure,  viz.,  atropine, 
paracentesis,  and  iridectomy.  The  beneficial  action  of  atropine,  both 
as  a  direct  sedative,  and  in  reducing  the  intra-ocular  tension,  has  been 
ah'eady  explained. 

If  the  ulcer  has  extended  so  deeply  into  the  substance  of  the  cornea 
as  to  thi'eaten  perforation,  no  time  should  be  lost  in  performing  para- 
centesis at  the  bottom  of  the  ulcer ;  for  by  so  doing,  we  shall  be  able  to 
limit  the  perforation  to  a  very  small  extent ;  for  if  we  permit  the  spon- 
taneous perforation  of  the  ulcer,  we  fijid  that  before  this  occurs  the 
bottom  of  the  ulcer  extends  somewhat  in  circumference,  and  thus  a  con- 
siderable ragged  opening  may  result,  and  the  latter  will  certainly  be 
much  larger  than  if  it  had  simply  been  made  with  a  fine  needle.  More- 
over, the  escape  of  the  aqueous  humour  will,  in  the  former  case,  be  more 
sudden  and  forcible,  which  is  apt  to  produce  considerable  hyperaemia 
ex  vacuo  of  the  deeper  tunics  of  the  eyeball ;  prolapse  of  the  iris,  which 
may  lead  to  suppurative  iritis  or  ii'ido-choroiditis ;  or  rupture  of  the 
capsule,  and  consequent  cataract ;  or  again,  the  suspensory  hgament  of 
the  lens  may  be  torn,  and  the  lens  partially  dislocated.  The  paracentesis 
should  not  be  postponed  until  the  deepest  layers  of  the  cornea  are 
implicated,  for  we  then  run  the  risk  of  a  large  spontaneous  perforation 


114  DISEASES   OF   THE   CORNEA. 

occurring  before  we  have  time  to  interfere.  The  puncture  should  be 
made  with  a  fine  needle  at  the  deepest  portion  of  the  ulcer,  and  the 
aqueous  humour  allowed  to  flow  off  as  gently  as  possible.  The  iris 
will  gradually  move  forward,  and  come  in  contact  with  the  back  of  the 
cornea  ;  a  thin  layer  of  lymph  will  be  effused  at  the  bottom  of  the  ulcer, 
under  which  the  regeneration  of  the  corneal  tissue  will  take  place,  the 
iris  being  generally  more  or  less  glued  to  the  perforation  by  the  effusion 
of  lymph.  As  soon  as  the  opening  is  stopped  by  this  plug  of  lymph, 
the  aqueous  humour  will  re-accumulate,  and  if  the  adhesion  between 
the  iris  and  cornea  is  but  slight,  it  will  readily  yield  to,  and  be  torn 
away  by,  the  force  of  the  aqueous  humour  and  the  action  of  the  muscles 
of  the  iris.  But  if  the  layer  of  lymph  at  the  bottom  of  the  ulcer  is 
thin  and  weak,  the  force  of  the  intra-ocular  pressure  may  rupture  it,  or 
may  cause  it  to  bulge  forward,  and  thus  necessitate  a  repetition  of  the 
paracentesis.  The  latter  should  also  be  repeated,  perhaps  even  several 
times,  if  we  notice  that  the  process  of  repair  becomes  arrested,  and 
that  the  ulcer  again  shows  a  tendency  to  increase  in  depth.  After  the 
operation  a  compress  bandage  should  be  applied.  If  the  ulcer  is 
extensive,  and  if  hypopyon  or  iritis  co-exist,  the  puncture  should  be 
made  with  a  broad  needle  at  the  edge  of  the  cornea,  or  an  iridectomy 
should  be  substituted.  The  indications  which  should  guide  us  in 
selecting  between  these  two  operations  have  already  been  considered 
in  the  article  u.pon  suppurative  corneitis.  In  cases  of  obstinate  ulcera- 
tion of  the  cornea,  confined  especially  or  entirely  to  one  portion  of  the 
latter,  much  benefit  is  sometimes  derived  from  syndectomy  of  the  cor- 
responding segment  of  the  sclerotic ;  so  that  the  blood  supply  of  the 
affected  portion  of  the  cornea  may  be  more  or  less  cut  off.  In  obsti- 
nate chronic  vascular  ulcers  of  the  cornea,  which  have  long  resisted 
every  form  of  treatment,  and  show  a  great  tendency  to  recur,  the 
insertion  of  a  seton  at  the  temple  often  renders  the  most  marked  and 
striking  benefit,  the  disease  being  rapidly  cured,  and  the  relapses  pre- 
vented, if  the  seton  is  worn  for  some  time  after  the  corneal  ulcer  is 
healed. 

We  are  especially  indebted  to  Mr.  Critchett  for  introducing  this 
mode  of  treatment*  in  certain  cases  of  chronic  vascular  ulcers  of  the 
cornea,  which  are  especially  characterised  by  their  protracted  course, 
their  great  tendency  to  recur,  and  the  obstinacy  with  which  they  resist 
all  ordinary  methods  of  treatment.  Mr.  Critchett  has  favoured  me 
with  the  following  description  of  the  manner  in  which  the  seton  is  to 
be  applied : — 

"  I  generally  use  rather  stout  silk  or  fine  twine,  such  as  a  large 
suture  needle  will  carry.     I  select  a  spot  near  the  temporal  region 

*  Mr.  Spencer  Watson  has  also  published  some  able  papers  upon  this  siibject 
in  the  "  R.  L.  O.  H.  Rep.,"  and  in  the  "  Medical  Mirror." 


ULCERS  OF  THE  CORNEA.  115 

under  the  liair,  so  as  to  avoid  as  far  as  possible  a  visible  scar.  Care  is 
required  not  to  wound  the  temporal  artery  ;  this  may  generally  be 
avoided  by  drawing  the  skin  well  away  from  the  temporal  fascia,  holding 
it  firmly  by  the  hair.  The  needle  is  thus  passed  through  at  a  level 
anterior  to  the  artery  ;  about  an  inch  is  usually  included,  and  a  loose 
loop  is  formed,  which  may  be  placed  behind  the  ear  ;  it  requires  to  be 
dressed  and  moved  daily ;  it  usually  continues  to  discharge  for  two  or 
three  months,  and  then  either  cuts  its  way  through,  or  dries  up.  In 
severe  and  obstinate  cases,  where  it  is  necessary,  it  may  be  renewed, 
selecting  a  spot  near  to  the  previous  scar.  I  have  sometimes  found  it 
desirable  to  continue  the  influence  of  a  seton  for  12  months.  There 
are  certain  inconveniences  that  occasionally  arise  to  which  I  may  briefly 
allude.  It  will  sometimes  happen  that  in  spite  of  every  care  and  pre- 
caution a  branch  of  the  temporal  artery  is  pricked  by  the  point  of  the 
needle  as  it  traverses  the  skin ;  this  accident  is  at  once  recognised  by 
the  rapid  outflow  of  arterial  blood  from  one  or  both  openings,  through 
which  the  silk  passes.  In  the  event  of  such  an  accident,  it  is  better  at 
once  to  remove  the  silk,  and  then  moderate  pressure  checks  the  bleed- 
ing, and  in  a  few  days  a  neighbouring  spot  may  be  selected  for  the 
re- introduction  of  the  silk;  but  if  this  precaution  be  not  taken,  and  if  an 
efibrt  be  made  to  retain  the  seton  in  spite  of  the  haemorrhage,  there  is  a 
great  liability  to  secondary  bleeding,  to  extravasation  of  blood  beneath 
the  scalp,  burrowing  abscesses,  and  other  untoward  casualties,  and  in  one 
instance  I  observed  the  formation  of  a  small  traumatic  aneurism.  In 
certain  exceptional  cases  the  introduction  of  the  seton  is  followed  by 
considerable  swelling  of  the  surrounding  parts,  with  a  tendency  to 
erysipelas,  and  suppurative  inflammation  cannot  be  established.  As  soon 
as  these  symptoms  show  themselves  the  silk  should  be  removed." 

If  an  ulcer  is  situated  at  or  near  the  centre  of  the  cornea,  and  per- 
foration appears  inevitable,  the  pupil  must  be  kept  widely  dilated  with 
atropine,  in  order  that  when  the  cornea  gives  way  and  the  aqueous 
humour  escapes,  the  edge  of  the  pupil  may  not  be  involved  in  the 
perforation.  On  the  other  hand,  if  the  ulcer  is  situated  near  the 
margin  of  the  cornea,  the  reverse  is  indicated,  and  the  pupil  should  be 
allowed  to  remain  undilated,  or  even  stimulated  to  extreme  contraction, 
by  the  appHcation  of  the  extract  of  the  Calabar  bean,  in  order  to 
remove  the  edge  of  the  pupil  as  far  as  possible  from  the  situation  of  the 
threatening  perforation.  Either  of  these  remedies  is  also  indicated 
when  a  slight  adhesion  exists  between  the  cornea  and  iris  (anterior 
synechia),  for,  by  the  strong  action  of  the  miiscles  of  the  iris  which 
they  produce,  the  adhesion  may  be  forcibly  torn  through. 

If  a  slight  prolapse  has  occurred,  we  must  at  once  attempt  to 
replace  it  by  pressing  it  gently  back  with  a  spatula  or  probe,  or  we 
may  endeavour  to  cause  it  to  recede  by  widely  dilating  the  pupil  by 

I  2 


116  DISEASES   OP   THE   CORNEA. 

atropine.  A  firm  compress  sliould  be  applied  in  all  cases  of  prolapse, 
for  it  will  favour  the  consolidation  of  the  wound  by  the  formation  of 
a  layer  of  lymph  over  the  prolapse,  and  will  prevent  the  latter  from 
yielding  to  the  intra-ocnlar  pressure  and  increasing  in  size.  The  pro- 
truding portion  of  iris  should  also  be  pricked  with  a  fine  needle,  and 
the  aqueous  humour  be  allowed  to  escape  ;  for  this  will  cause  the  prolapse 
to  shrink  and  gradually  dwindle  down.  This  operation  may  be  repeated 
several  times,  and  generally  with  the  best  results  ;  but  if  the  prolapse 
is  large  and  prominent,  it  should  be  first  pricked  with  the  needle,  and 
then,  when  the  escape  of  the  aqueous  humour  has  caused  it  to  collapse, 
it  should  be  seized  with  a  pair  of  iridectomy  forceps,  and  snipped  off 
with  a  pair  of  curved  scissors  quite  close  to  the  cornea,  a  firm  compress 
being  at  once  applied.  The  same  treatment  is  to  be  pursued  in 
staphyloma  rridis. 

Some  surgeons  recommend  that  the  prolapse  should  be  touched 
with  a  point  of  nitrate  of  silver,  or  with  a  little  vinum  opii ;  but 
this  is  apt  to  set  up  great  irritation,  and  may  even  produce  severe 
iritis.  If  it  be  done  at  all,  a  weak  solution  of  nitrate  of  silver  should 
be  lightly  applied  to  the  apex  of  the  prolapse,  with  a  fine  camel's 
hair  bi'ush.  In  a  considerable  and  obstinate  prolapse,  much  benefit  is 
generally  derived  from  makiug  a  large  iridectomy  in  an  opposite 
direction,  for  this  will  often  cause  the  prolapse  to  recede  and  flatten. 
This  operation  is  also  indicated  when  the  pupil  is  partly  or  wholly 
implicated  in  the  prolapse  or  anterior  synechia ;  also,  when  there  is  a 
partial  staphyloma,  and,  above  all,  when  this  is  accompanied  by  an 
increase  in  the  intra-ocular  tension.  For,  as  has  been  pointed  out  by 
Von  Graefe,  in  cases  of  partial  or  complete  staphyloma,  or  of 
leucoma  prominens,  the  degree  of  blindness  is  frequently  quite  dis- 
proportionate to  the  optical  condition.  In  such  cases  there  is  often 
contraction  of  the  visual  field,  eccentric  fixation,  increase  in  the  intra- 
ocular pressure,  and  excavation  of  the  optic  nerve.  When  glaucomatous 
symptoms  supervene  upon  partial  staphyloma,  or  leucoma  prominens, 
we  find  the  cornea  becomes  at  this  point  markedly  prominent,  even 
after  it  has  already  become  thickened  and  consolidated. 

Fistula  of  the  Cornea  often  proves  very  obstinate  and  intractable, 
and  even  dangerous  to  the  eye,  leading  perhaps  finally  to  irido- 
choroiditis  and  atrophy  of  the  eyeball.  A  fistulous  opening  of  the 
coi-nea  may  result  from  a  small  perforating  ulcer  of  the  cornea,  or 
from  a  wound  of  the  latter,  with  or  without  injury  to  the  lens.  The 
fistulous  opening  may  become  temporarily  closed,  so  that  tbe  aqueous 
humour  re-accumulates,  but  after  a  short  interval  it  again  gives  way, 
the  aqueous  fiows  ofi*,  and  the  anterior  chamber  is  obliterated.  This 
may  occur  over  and  over  again.  When  fistula  of  the  cornea  exists,  the 
eye  remains  irritable  and  injected,  the  intra-ocular  tension  is  greatly 


DIFFUSE  CORNEITIS.  117 

diminislied,  the  anterioi'  chamber  obliterated,  and  a  small  drop  of  fluid 
may  be  noticed  exuding  through  the  aperture  in  the  cornea.  Various 
modes  of  treatment  have  been  advocated.  At  the  outset  a  firm  com- 
press bandage  should  be  appHed,  as  well  as  a  strong  solution  of 
atropine,  and  if  this  fails  to  heal  the  fistula,  the  latter  may  be 
touched  with  the  point  of  a  fine  camel's  hair  brush  dipped  in  a  weak 
solution  of  nitrate  of  silver,  this  being  repeated  several  times  at  an 
interval  of  a  day  or  two.  The  disadvantage  of  this  mode  of  treatment 
is,  however,  that  it  often  produces  an  indehble  cicatrix.  An  iridectomy 
frequently  proves  of  more  service.  Wecker*  considers  that  the  fistula  is 
due  to  an  eversion  of  the  membrane  of  Descemet  at  this  point,  and  has 
therefore  devised  the  following  treatment.  He  introduces  into  the 
opening  a  very  fine  smooth-pointed  straight  pair  of  forceps,  and,  seizing 
the  wall  of  the  fistulous  track,  bruises  its  hning,  and  thus  denudes  the 
corneal  tissue.  This  having  been  done  at  several  points,  atropine  and 
a  compress  bandage  must  be  applied.  Great  care  and  delicacy  are 
required  not  to  rupture  the  capsule  with  the  point  of  the  forceps.  He 
has  thus  cui'ed  a  case  of  fistula  of  the  cornea,  which  had  resisted  for  ten 
months  diSerent  modes  of  treatment.  Zehenderf  has  found  the  pro- 
longed use  of  the  extract  of  Calabar  bean  of  great  service  in  curing  a 
corneal  fistula. 


7.— DIFFUSE    CORNEITIS    (PARENCHYMATOUS, 
INTERSTITIAL,  SYPHILITIC). 

In  this  disease  we  may  also  distinguish  two  principal  forms.  The 
one  is  accompanied  by  raarked  symptoms  of  inflammation,  and  is  hence 
called  "vascidar  diSuse  corneitis."  In  the  other,  or  "  non- vascular" 
form,  these  symptoms  are  entirely  absent. 

1.  In  the  vascular  diffuse  corneitis  we  notice,  together  with  a  certain 
varying  degree  of  conjunctival  and  subconjunctival  injection,  a  zone  of 
vessels  passing  from  the  margin  of  the  cornea  more  or  less  towards  the 
centre,  where  they  terminate  in  a  sharply  defined  line.  They  are  not 
situated  on  the  surface  of  the  cornea,  as  those  in  pannus,  but  enter 
deeply  into  its  substance.  They  consist  in  part  of  vessels  derived  from 
the  junction  of  the  conjunctival  and  subconjunctival  vessels  near  the 
margin  of  the  cornea,  and  in  part  also  of  branches  coming  from  the 
blood-vessels  of  the  ciKary  body.  Sometimes  the  vascularity  at  the 
edge  of  the  cornea  is  so  great,  that  it  looks  like  a  bright  red  zone  of 
extravasated  blood.  Soon  there  is  noticed  at  one  or  more  points,  a 
slight  opacity  of  the  cornea,  which  genci^lly  commences  at  the  margin 

*  "  Annales  d'Oculistique,"  rol.  56,  305. 
t  "  Kl.  Monatsbl.,"  1868,  35. 


118  DISEASES   OF   THE  CORNEA. 

where  its  density  is  greatest,  and  gradually  shades  off  towards  the 
centre  into  transparent  cornea.  Sometimes,  however,  the  opacity 
begins  at  the  centre,  Avhence  it  slowly  extends  towards  the  periphery. 
The  cloudiness  gradually  increases  in  extent  and  thickness,  until  the 
whole  surface  of  the  cornea  may  become  diffusely  opaque.  The  density 
and  colour  of  the  opacity  vary  a  good  deal.  Thus,  it  may  be  but 
thin,  and  of  a  greyish  white  colour,  having  very  much  the  appearance 
of  frosted  glass,  or  it  may  be  thicker  and  of  a  yellowish  creamy  tint, 
more  especially  in  the  centre  of  the  cornea.  Indeed,  at  this  point  we 
not  unfrequently  see  a  large  circular  patch  of  a  pale  yellow  colour, 
which  is  evidently  deeply  seated  in  the  substance  of  the  cornea.  This 
central  patch  may  gain  a  considerable  size,  even  of  two  or  three  lines  in 
diameter.  Sometimes  several  such  denser  patches  may  be  noticed  at 
different  points.  The  epithehal  layer  at  first  retains  its  normal  smooth- 
ness, but  after  a  time  it  becomes  somewhat  rough  and  thickened,  as  if 
it  had  been  lightly  pricked  by  a  pin,  or  a  fine  powder  had  been  strewn 
over  it.  The  disease  shows  very  little  tendency  to  ulceration  or  to 
purulent  necrosis,  unless  it  has  been  very  injudiciously  treated  by 
caustics  or  strong  astringent  collyria.  But  the  whole  surface  of  the 
cornea  may  be  swollen  and  become  somewhat  prominent,  yielding  here 
and  there  to  the  intra-ocular  pi*essui'e  and  bulging  forward.  Generally 
these  prominences  disappear  with  the  infiltration,  but  if  they  have  been 
considerable,  they  may  leave  behind  some  impairment  of  the  true  cur- 
vature of  the  cornea.  The  amount  of  inflammation  and  ciliary 
irritation  vary  very  much.  Sometimes  there  is  very  considerable  and 
obstinately  persistent  photophobia,  together  with  lachrymation  and  a 
certain  degree  of  ciliary  neuralgia.  In  other  cases  these  symptoms  never 
assume  any  particular  prominence.  The  sight  is  always  greatly  im- 
paired, so  that  the  patient  can  hardly  see  a  hand  moving,  which  is  due 
to  the  diffuse  character  of  the  opacity,  for  it  is  as  if  he  were  looking 
through  a  piece  of  ground  glass.  If  both  eyes  become  affected,  which 
is  generally  the  case,  the  effect  of  this  total  loss  of  sight  is  most  depress- 
ing, and  demands  the  greatest  confidence  in  the  surgeon  to  prevent 
the  patient  from  seeking  other  and  perhaps  injudicious  advice.  For 
the  disease  runs  a  most  slow  and  protracted  course ;  months  and 
months  elapse  before  any,  even  slight,  improvement  begins  to  show 
itself,  and  during  all  this  time  no  treatment  appears  of  any  special  ser- 
vice. We  can  but  let  the  disease  run  its  course,  and  endeavoiir  to 
guide  it  in  its  progress.  It  may  take  from  six  to  eight  weeks  until  it 
has  reached  its  acme ;  the  cornea  being  then,  perhaps,  almost  covered 
with  closely  crowded  blood-vessels,  which  reach  almost  up  to  its 
very  centre,  where  is  seen  a  thick  yellow  infiltration.  The  red  appear- 
ance of  the  cornea  is  often  increased  by  small  extravasations  of  blood, 
caused  by  the  giving  way  of  some  of  the  vessels.     The  disease  may 


DIFFUSE   CORNEITIS.  119 

now  remain  stationary  for  a  few  weeks,  and  then  the  process  of  repara- 
tion sets  in.  The  vascularity  diminishes  ;  the  vessels  are  less  closely 
arranged  at  the  edge  of  the  cornea,  and  show  more  or  less  considerable 
gaps  between  them ;  and  the  infiltration  becomes  thinner  and  lighter 
in  colour,  gradually  disappearing  more  and  more  fi'om  the  periphery 
towards  the  centre,  which  is  the  last  to  clear  up. 

The  prognosis  of  the  disease  is,  on  the  whole  favourable,  for 
although  it  runs  a  most  protracted  course,  which  may  extend  over  many 
months,  and  although  the  opacity  of  the  cornea  may  be  so  dense  as  to 
prevent  the  patient  from  even  counting  fingers,  there  is  no  tendency  to 
ulceration  of  the  cornea,  and  the  opacity  gradually  disappears  until 
there  is  finally  perhaps  only  a  slight  cloudiness  left.  Both  eyes  are 
generally  afiected,  and  this  renders  the  aSection  of  course  the  more 
harassing  and  alarming  to  the  patient,  who  may  thus  remain  for  many 
weeks  almost  totally  blind.  Iritis  is  a  frequent  accompaniment  of  the 
inflammation  of  the  cornea,  and  may  be  quite  unsuspected  during  the 
progress  of  the  case,  as  the  iris  is  hidden  from  view  by  the  opacity  of 
the  cornea ;  and  it  is  only  when  the  latter  becomes  clearer  that  the  iris 
is  found  somewhat  discoloured,  and  the  pupil  irregular  and  adherent. 
But  a  still  graver  and  more  dangerous  complication  is  inflammation  of 
the  ciliary  body,  which  is  especially  apt  to  occur  if  the  case  has  been 
carelessly  treated,  or  caustic  or  strong  astringent  coll}Tia  have  been 
appKed.  "We  must  suspect  this  complication,  if  the  symptoms  of  inflam- 
matory irritation  are  greatly  increased  in  intensity,  if  the  vascularity, 
photophobia,  lachrymation,  and  ciliary  neuralgia  are  severe,  if  the  sight 
is  rapidly  diminished,  and  the  field  of  vision  markedly  contracted,  and 
if  the  eye  at  the  region  of  the  ciliary  body  is  extremely  sensitive  to 
the  touch. 

Difi'use  corneitis  is  especially  apt  to  occur  between  the  ages  of  five 
and  twenty,  but  it  may  be  met  with  up  to  tliirty-five  or  forty.  It 
generally  occurs  in  persons  in  a  feeble,  delicate  state  of  health,  which 
may  be  due  to  numerous  causes,  such  as  want  and  privation,  very  hard 
and  fatiguing  work,  more  especially  in  a  confined  or  vitiated  atmosphere; 
and  it  is  often  met  with  in  persons  afiected  with  a  scrofulous  diathesis, 
or  with  inherited  syphilis.  I  cannot  at  all  agree  with  the  view  that 
diffuse  corneitis  is  always  due  to  inherited  sj'philis,  for  although 
I  have  often  seen  it  associated  with  the  latter,  yet  it  many  cases 
not  the  slightest  trace  of  a  syphilitic  taint  could  be  ascertained,  and 
there  was  a  marked  and  complete  absence  of  the  peculiar  syphilitic 
features  and  the  notched  teeth.  Indeed,  I  think  that  we  are  often  too 
apt  hastily  to  jump  to  the  conclusion  that  hereditary  syphilis  exists, 
when  on  a  more  careful  and  searching  examination  into  some  of  these 
histories,  it  would  be  found  that  the  miscarriages,  early  deaths  of  the 
children,  etc.,  were  due  to  perfectly  natural  causes,   and  quite  iude- 


120  DISEASES  OP  THE  CORNEA. 

pendent  of  any  sypliilitic  taint.  I  may  of  course  be  met  ■with  tlie 
constantly  recurring  argument  that  it  is  impossible  to  get  at  the  truth 
of  the  history,  but  I  think  that  we  are  justified  in  giving  the  patient 
and  his  parents  the  benefit  of  the  doubt,  if  no  reliable  proof  of  the 
presence  of  inherited  syjDhilis  can  be  made  out.  For  this  reason,  I 
must  completely  disagree  with  those  authors  who  term  this  disease 
"syphilitic  corneitis."  For,  as  I  have  already  stated,  it  is  frequently 
met  with  in  persons,  in  whom  not  the  slightest  trace  of  a  syphilitic 
taint  can  be  detected.  Whilst  combating  some  of  these  views,  I  must, 
however,  seize  this  opportunity  to  express  my  admu-ation  for  the  very 
important  and  interesting  researches  of  Mr.  Jonathan  Hutchinson,* 
into  the  frequent  connection  between  inherited  syphilis  and  many  of 
the  diseases  of  the  eye,  a  discovery  which  has  proved  of  great  im- 
portance and  use  in  the  treatment  of  these  affections. 

In  the  treatment  of  this  disease,  we  must  be  chiefly  contented  with 
guarding  the  eye  against  all  noxious  influences,  such  as  bright  light, 
wind,  draughts,  etc.,  and  must  endeavour  to  prevent  the  inflammatory 
symptoms  from  gaining  an  undue  prominence.  Unfortunately  we  do 
not  at  present  know  of  any  means  of  checking  the  progress  and 
development  of  the  disease,  or  of  curtailing  its  protracted  course. 
The  use  of  caustics  or  astringent  collyria  must  be  most  carefully 
avoided,  as  they  only  tend  to  increase  the  inflammatory  irritation  and 
to  produce  complications,  such  as  ulcers  of  the  cornea,  or  inflammation 
of  the  iris  or  ciliary  body.  At  the  outset,  atropine  should  always  be 
applied,  although  when  the  cornea  becomes  diflusely  clouded,  it  is  but 
of  little  use,  as  it  is  not  absorbed,  and  it  is  apt  to  increase  the  inflanmia- 
tion  if  it  be  too  long  continued.  But  when  the  cornea  begins  to  clear, 
atropine  or  the  belladonna  collyrium  should  be  again  applied.  Local 
depletion  and  very  antiphlogistic  treatment  are  not  well  borne  on  account 
of  the  weakly  and  feeble  health  of  the  patient.  Moreover,  they  tend 
to  impede  the  formation  of  blood-vessels  on  the  cornea,  and  to  protract 
the  course  of  the  disease.  But  if  symptoms  of  cyclitis  make  their 
appearance,  leeches  should  be  applied  to  the  temple,  and  paracentesis 
should  be  performed ;  and  if  the  sight  deteriorates  greatly,  the  field  be- 
comes contracted,  and  especially  if  the  intra-ocular  tension  increases,  an 
iridectomy  should  be  made  at  once.  When  the  cornea  is  beginning  to 
clear  up,  the  absorption  of  the  morbid  products  may  be  hastened  by 
applying  slight  irritants.  The  best  to  commence  with,  is  the  insufiia- 
tion  of  calomel,  which  should  be  employed  once  daily.  If  the  eye 
bears  this  well  without  becoming  too  much  irritated,  the  yellow  pre- 
cipitate ointment  should  be  substituted  for  it.     At  first  I  generally 

*  Vide  Mr.  Hutcliinsou's  admirable  work,  "  Sypliilitic  Diseases  of  the  Eye  aud 
Ear." 


DIFFUSE   CORNEITIS.  121 

employ  it  of  about  tlie  strength  of  two  grains  to  the  drachm,  and  use 
but  a  very  small  quantity.  If  it  excites  much  irritation,  I  use  a  still 
weaker  mixture,  or  postpone  its  use  for  a  few  days.  I  have  found  it 
by  far  the  best  remedy  for  accelerating  the  absorption  of  opacities  of 
the  cornea.  A  collyrium  of  iodide  of  potassium  (gr.  ij  ad  ^j)  is  also 
serviceable  for  this  purpose.  Hasner  has  practised  paracentesis  in 
some  of  these  cases  of  diffuse  corneitis. 

It  is  of  great  importance  to  attend  to  the  general  health  of  the  patients, 
as  they  are  as  a  rule  of  a  feeble  cachectic  habit.  Tonics,  especially  the 
syrup  of  the  iodide  of  ii'ou,  quinine,  or  the  citrate  of  quinine  and  steel 
should  be  administered.  Cod- liver  oil,  with  or  without  quinine  or  steel 
is  also  of  much  benefit.  If  a  syphilitic  taint  is  suspected,  the  iodide 
and  bromide  of  potassium  in  combination  with  the  bichloride  of  mer- 
cury and  cinchona,  may  be  given  with  much  advantage.  The  diet 
should  be  nutritious  and  easily  digestible.  Meat  may  be  allowed 
two  or  three  times  daily,  and  wine  and  malt  liquor  may  be  freely 
administered.  In  fact  everything  should  be  done  to  strengthen  the 
patient.  In  hospital  practice,  I  have  often  been  obliged  to  take  such 
patients  into  the  house  for  many  months,  in  order  that  they  might  have 
m.ore  attention,  and  a  more  generous  diet  than  they  would  have  ob- 
tained at  home.  When  the  acute  stage  is  past,  and  the  cornea  is 
beginning  to  clear,  the  patient  should,  if  possible,  be  sent  into  the 
country,  or  still  better  to  the  sea  side,  and  enjoy  a  gTeat  deal  of  out- 
of-door  exercise.  The  obstinate  photophobia  and  chronic  irritability 
of  the  eye,  which  often  prove  so  troublesome,  yield  sometimes  most 
rapidly  to  change  of  air. 

2.  In  the  non-vascular  diffuse  corneitis,  we  notice  that  a  small  cloud 
appears  in  the  centre  of  the  cornea,  unaccompanied  by  any  but  the 
slightest  symptoms  of  irritation,  and  there  is  only  a  very  faint  rosy  in- 
jection around  the  cornea,  but  not  extending  on  to  it.  In  the  course  of 
ten  or  fourteen  days  the  opacity  extends  over  the  whole  surface  of  the 
cornea,  giving  it  the  appearance  of  ground  glass,  or  of  a  mirror  that 
has  been  lightly  breathed  upon.  The  symptoms  of  irritation,  espe- 
cially the  photophobia,  may  now  increase  somewhat,  but  the  vascularity 
remains  slight.  The  vessels  never  become  very  numerous  or  closely 
crowded  together,  as  is  the  case  in  the  vascular  form ;  but  individual 
vessels  straggle  on  towards  the  infiltration,  and  do  not  terminate 
uniformly  in  a  defined  line.  The  opacity  gradually  becomes  somewhat 
more  dense  and  yellow  towards  the  centre,  and  then,  after  a  time,  clears 
up  at  the  periphery,  and  the  infiltration  slowly  disappears  in  a  centri- 
petal direction.  The  course  of  this  form  is  also  extremely  protracted, 
and  many  months  may  elapse  until  the  cornea  regains  its  transparency. 
The  prognosis  is  still  more  favourable  than  in  the  vascular  form,  for 
there  is  far  less  tendency  to  complications  with  inflammation  of  the  iris 


122  DISEASES  OF   THE   CORNEA. 

or  ciliary  body,  or  to  ulceration  of  the  cornea ;  although  the  latter  may 
be  produced  if  strong  caustics  or  astringents  be  employed. 

The  causes  are  the  same  as  in  the  vascular  form.  If  there  is  any 
marked  irritability  of  the  eye,  this  should  be  treated  by  atropine,  cold 
compresses,  blisters,  etc.  But  in  the  majority  of  the  cases  just  the 
reverse  obtains,  the  progress  of  the  affection  languishes  and  becomes 
torpid,  and  there  is  a  complete  absence  of  all  symptoms  of  inflam- 
matory irritation.  In  such  cases  it  is  advisable  to  apply  a  slight 
irritant,  more  especially  the  yellow  oxide  of  mercury  ointment  every 
day  for  a  few  days.  This  will  excite  a  little  irritation,  the  central 
portion  of  the  inflammation  will  become  somewhat  more  thick  and 
yellow,  and  the  progress  of  the  disease  will  become  accelerated.  It 
has  often  been  noticed  that  a  certain  amount  of  conjunctivitis  is  very 
favourable.  Thus,  if  the  patient  suffering  from  this  form  of  corneitis, 
by  accident  contracts  catarrhal  ophthalmia,  the  progress  of  the  affection 
of  the  cornea  will  be  greatly  hastened,  and  an  infiltration  disappear 
in  a  few  weeks,  which  would  otherwise  have  taken  many  months  before 
it  had  become  absorbed.  This  fact  led  Von  Graefe  to  employ  warm 
fomentations  in  these  cases,  in  order  to  excite  a  certain  degree  of 
inflammatory  swelling  of  the  conjunctiva.  They  are  indicated  if  the 
vascularity  and  irritation  are  but  very  slight,  and  the  progress  of  the 
disease  extremely  protracted  and  sluggish.  They  must  be  employed 
with  care  and  circumspection,  so  that  they  may  not  excite  too  much 
inflammation  of  the  conjunctiva,  which  would  retard  instead  of  hastening 
the  absorption  of  the  infiltration,  and  perhaps  leave  it  incomplete. 

8.— OPACITIES  OF  THE  CORNEA. 

These  vary  much  in  situation,  extent,  and  thickness.  If  they  are 
quite  superficial  and  thin,  looking  like  a  faint  greyish  blue  cloud,  they 
are  termed  nebulae.  If  the  opacity  is  of  a  denser,  white,  pearly,  tendin- 
ous appearance,  and  situated  more  deeply  in  the  substance  of  the 
cornea,  it  is  called  an  albugo  or  leucoma. 

A  temporary  diffuse  opacity  of  the  cornea  may  be  produced  by  sudden 
increase  of  the  iutra-ocular  pressure,  as  in  certain  forms  of  glaucoma, 
etc.  This  opacity  is  probably  due  in  part  to  a  displacement  of  some  of 
the  corneal  elements,  and  also,  perhaps,  to  a  disturbance  of  the 
nutrition  of  the  cornea  from  the  compression  of  the  nerves. 

We  meet  with  a  very  superficial  opacity  of  the  cornea,  which  is 
due  to  changes  in  the  epithelial  layer.  Here  and  there  the  epithelial 
cells  become  thickened,  aggregated  together,  and  opaque,  their  con- 
tents having  perhaps  undergone  fatty  degeneration.  These  opacities 
are  of  a  faint  grey,  or  bluish  grey  colour,  with  an  irregular  margin.    In 


OPACITIES   OF   THE   CORNEA.  123 

their  centre,  the  reflection  of  an  object,  for  instance  a  window,  will 
be  found  indistinct,  or  more  or  less  distorted.  Generally  they  are 
easUy  observable.  They  may,  however,  be  so  slight  as  to  escape  detec- 
tion, but  become  very  evident  with  the  oblique  illumination.  They 
occur  after  the  superficial  forms  of  corneitis,  especially  pannus  due  to 
disticliiasis  or  granular  lids,  and  also  after  sujDerficial  ulcers  of  the 
cornea. 

The  deeper  opacities,  which  are  situated  in  the  substance  of  the 
cornea  itself,  may  be  confined  to  a  certain  portion  of  it  (partial  leucoma) 
or  extend  over  its  whole  surface  (total  leucoma).  The  cloudiness  may 
either  be  of  a  uniform  greyish  blue,  or  greyish  white  colour,  or  may  be 
made  up  of  several  opaque  white  patches  or  spots  of  varying  extent 
and  shape.  The  outline  of  these  opacities  is  irregular  and  not  sharply 
defined,  being  shaded  gradually  ofi"  into  the  normally  transparent 
cornea.  Their  thickness  and  colour  also  vary  much,  from  a  greyish 
blue  to  a  yellowish  white  and  densely  opaque  tint.  The  epithelial  layer 
is  often  ii^regular  and  punctated,  as  if  a  fine  powder  had  been  dusted 
over  it,  and  this  causes  a  distortion  of  the  reflected  image.  Or,  again, 
the  opacities  may  look  like  little  opaque  chalky  nodules  stre^vn  about 
on  difierent  portions  of  the  cornea  (generally  near  its  sm^face),  and  are 
the -remains  of  phlyctenulae. 

Fine  punctated  opacities  are  also  met  with  on  the  posterior  surface  of 
the  cornea.  They  are  generally  arranged  in  the  form  of  a  pyramid,  with 
its  base  downwards,  and  are  chiefly  due  to  a  precipitation  of  lymph  on 
the  posterior  wall  of  the  cornea,  but  also  perhaps  to  inflammatory  changes 
in  the  posterior  epithelial  layer.  These  peculiar  opacities  are  observed 
in  serous  iritis  (sometimes  termed  aquo  capsulitis,  corneitis  punctata, 
etc.),  and  also  in  inflammations  of  the  deeper  tunics  of  the  eyeball,  and 
sympathetic  ophthalmia.  In  the  latter  cases,  similar  punctated 
opacities  may  also  occur  on  the  anterior  surface  of  the  cornea.  The 
difierent  opacities  which  we  have  mentioned  are  chiefly  due  to  inflam- 
matory changes  in  the  corneal  and  epithelial  cells,  and  are  capable  of 
undergoing  almost  complete  absorption,  so  that  they  may  hardly  leave 
a  trace  behind  them.  It  is  necessary  to  distinguish  from  them  another 
form  of  opacity  which  is  dependent  upon  permanent  change,  often  of  a 
tendinous  or  cicatricial  nature,  and  hence  does  not  undergo  absorption, 
but  remains  indelible.  These  opacities  are  more  regular  and  sharply 
defined  in  their  outline,  and  have  a  more  uniform  tendinous,  glistening 
white  or  chalky  appearance,  having,  perhaps,  a  deposit  of  fatty  or 
earthy  matter  in  the  centre.  The  epithelial  layer  is  smooth  and  not 
irregular.  These  cicatrices  vary  in  extent  and  shape,  in  accordance 
wilh  the  size  and  depth  of  the  original  ulcer ;  they  do  not,  however, 
correspond  exactly  to  it,  because  a  portion  of  the  latter  is  very 
frequently  filled  up  by  transparent  corneal  tissue.     These  cicatricial 


124  DISEASES  OP  THE  CORNEA. 

opacities  occur  very  frequently  together  with  those  due  to  inflamma- 
tory changes,  so  that  we  have  the  two  forms  existing  together.  The 
cicatrix,  instead  of  being  sharply  defined,  is  then  surrounded  by  a  more 
or  less  wide  opaque  areola  of  inflammatory  infiltration.  The  latter  may 
in  time  become  completely  absorbed  and  transparent,  and  leave  only  the 
cicatricial  opacity,  which  will,  of  course,  be  now  considerably  less  in 
size  than  the  original  leucoma. 

In  cases  of  perforating  ulcer  of  the  cornea,  accompanied  with  ante- 
rior synechia,  the  cicatrix  to  which  the  iris  remains  attached  is  termed 
leucoma  adherens.  If  it  be  situated  near  the  centre  of  the  cornea,  a 
portion  of  the  pupil  will  be  included  in  it,  leaving,  perhaps,  the  other 
part  of  the  pupil  free,  and  opposite  a  transparent  portion  of  the 
cornea. 

A  peculiar  superficial  opacity  of  the  cornea  is  sometimes  met  with, 
which  is  due  to  calcareous  deposits  (consisting  of  phosphate  and  car- 
bonate of  lime)  in  the  anterior  elastic  lamina.  These  opacities  are  of 
a  mottled  brownish  hue,  with  an  indistinct  margin,  which  shades  ofi", 
more  or  less  abruptly,  into  the  healthy  cornea.  Their  course  is  very 
protracted,  and  they  are  apt  simultaneously  to  afiect  both  eyes.  Two 
very  interesting  cases  of  this  peculiar  opacity,  which  occurred  about  the 
same  time,  have  been  described  by  Mr.  Dixon*  and  Mr.  Bowman.f  In 
each  of  these  cases  a  portion  of  the  opacity  opposite  the  pupil  was 
scraped  off  with  a  scalpel,  and  was  found  to  consist  of  hard  gritty 
matter,  situated  just  beneath  the  epithelium.  The  result  of  the  opera- 
tion upon  the  sight  was  excellent.  Sometimes  earthy  or  metallic 
incrustations  are  formed  upon  the  cornea,  and  give  rise  to  peculiar 
opaque  or  chalky-looking  specks.  This  occasionally  occurs  from  the 
contact  of  quicklime  or  the  deposits  formed  from  lead  lotion  in  cases  of 
ulcers  or  abrasions  of  the  cornea. 

The  prognosis  in  cases  of  opacity  of  the  cornea  will  depend  very 
much  upon  the  age  and  constitution  of  the  patient,  and  upon  the  dura- 
tion, extent,  situation,  and  nature  of  the  opacity.  Thus,  in  children 
and  young  persons  in  good  health,  opacities,  the  result  even  of  extensive 
corneitis  or  deep  ulcers,  may  in  time  disappear  almost  completely, 
without  leaving,  perhaps,  any  trace  behind.  I  have  already  stated  that 
this  may  even  occur  in  small  perforating  ulcers  which  have  given  rise 
to  central  capsular  cataract.  With  regard  to  the  opacities  due  to  in- 
flammatory changes  in  the  corneal  tissue,  it  may  be  laid  down  as  a 
general  rule  that  the  more  recent,  superficial,  and  limited  such  opacities 
are,  the  more  rapidly  and  completely  do  they  disappear.  By  the 
application  of  irritants  to  the  eye,  we  may  greatly  assist  in  removing 
the  cloudiness  due  to  inflammatory  changes  in  the  corneal  and  epithe- 

*  "  Diseases  of  the  Eye,"  3rd  edition,  p.  114. 

f  "  Lectures  on  parts  concerned  in  tlic  Operations  on  the  Eye,"  pp.  38  and  117. 


OPACITIES  OF  THE  CORNEA.  125 

lial  cells.  We  thus  excite  hyperEemia  of  the  parts,  increase  the 
interchange  of  material,  and  accelerate  and  stimulate  the  process 
of  absorption.  When  the  opacities  are  due  to  permanent  cicatricial 
changes,  these  applications  are  of  no  avail,  and  we  must  then  have 
recourse  to  other  remedies  if  the  opacity  causes  any  impairment  of 
vision.  If  the  opacity  is  dense  and  situated  in  or  very  near  the  centre 
of  the  cornea,  the  sight  may  be  very  considerably  affected,  as  it  will  more 
or  less  cover  the  pupil.  But  even  slighter  opacities  may  somewhat  impair 
and  confuse  the  vision,  by  the  diffusion  and  nregular  refraction  of  the 
rays  of  light  which  they  produce.  But,  apart  from  this  effect  upon 
the  sight,  these  opacities  may  give  rise  to  other  complications.  Thus, 
on  account  of  the  indistinctness  of  the  retinal  image  produced  by  the 
cloudy  state  of  the  cornea,  the  patient  will  bring  small  objects  (as  in 
reading,  sewing,  etc.)  very  close  to  the  eye,  in  order  to  gain  a  larger 
and  more  distinct  image.  But  this  constant  accommodation  for  a  very 
near  point,  after  a  time  causes  the  lens  to  forfeit  some  of  its  elasticity, 
so  that  it  cannot  resume  its  original  form,  and  the  accommodation  cannot 
relax  itself  completely  when  the  eye  is  looking  at  distant  objects.  The 
lens  remains  too  convex,  and  the  eye  has  become  myopic.  The  latter 
may  be  also  in  part  due  to  a  change  in  the  shape  of  the  eyeball,  pro- 
duced by  constant  and  long- continued  accommodation  for  near  objects 
(u/fZe  article  "  Myopia").  Opacities  of  the  cornea  may  also  give  rise 
to  oscillation  of  the  eyeballs,  and  to  strabismus. 

Innumerable  local  remedies  have  been  recommended  for  the  disper- 
sion of  opacities  of  the  cornea.  From  amongst  these  we  may  select  the 
following  as  the  most  trustworthy  and  efficacious  : — The  insufflation  of 
calomel,  the  red  or  yellow  oxide  of  mercury  ointment,  collyria  of  iodide 
of  potassium,  vinum  opii,  nitrate  of  silver,  sulphate  of  copper,  and  the 
sulphate  of  soda.  Together  with  the  use  of  any  of  these  agents,  atro- 
pine should  be  appKed,  as  it  diminishes  the  intra-ocular  pressure,  and 
thus  facihtates  the  interchange  of  material  and  the  process  of  absorption. 
I  have  generally  found  it  best  first  to  dust  in  calomel  for  a  few  days, 
in  order  to  see  how  the  eye  bears  this,  and  then,  if  it  does  not 
excite  too  much  irritation,  to  employ  a  stronger  irritant,  especially 
the  red  or  yellow  oxide  of  mercury  ointment.  At  first  its  strength 
should  not,  I  think,  exceed  one  or  two  grains  to  the  drachm  of  lard. 
A  little  portion,  about  the  sjze  of  a  couple  of  jjins'  heads,  should  be 
placed  on  the  inside  of  the  lower  eyelid,  by  means  of  a  probe,  and  the  lids 
should  then  be  well  rubbed  over  the  cornea,  so  that  the  ointment  may 
come  well  in  contact  with  it.  If  the  yellow  precipitate  ointment  be 
used  of  gi'eater  strength  than  that  mentioned  above,  it  should  be 
removed  after  a  few  minutes,  otherwise  it  may  produce  too  much 
irritation.  If  it  is  found  that  the  ointment  excites  a  great  deal  of 
rritation,  redness,  and  pain,  a  smaller  quantity,  or  a  weaker  prepara- 


126  DISEASES   OP   THE   CORNEA. 

tion  should  be  used,  or  the  calomel  should  be  again  substituted  for  a 
few  days.  Generally  it  is  better  if  the  surgeon  can  himself  apply  these 
remedies,  as  he  is  then  able  to  watch  their  action  upon  the  eye ;  but 
if  the  proper  mode  of  using  the  calomel  and  the  ointment  be  ex- 
plained and  shown  to  the  patient,  I  have  found  no  difficulty  in  getting 
these  remedies  applied  by  the  patient  himself,  or  his  friends.  I  have 
also  found  advantage  from  the  application  of  iodide  of  potassium,  either 
in  a  collyi'ium  or  mixed  with  the  yellow  precipitate,  in  the  following 
proportion  : — Iodide  of  Potassium  gr.  j.,  Yellow  Oxide  of  Mercury  gr.  ij., 
Adipis  5j. — 5ij.  The  instillation  of  a  little  vinum  opii  also  proves  very 
useful.  The  nitrate  of  silver  or  sulphate  of  copper  are  only  indicated 
when  there  is  any  inflammatory  swelling  of  the  conjunctiva,  accompa- 
nied by  some  muco-purulent  discharge.  After  any  of  these  remedies 
have  been  used  for  some  length  of  time,  they  should  be  exchanged  for 
some  other  agent,  as  the  eye  gets  accustomed  to  them,  and  they  appear 
temporarily  to  lose  their  effect. 

Electricity  was  formerly  in  vogue  for  the  cure  of  opacities  of  the 
cornea.     It  has  now,  however,  fallen  into  disuse. 

Dr.  Rothmund,*  of  Munich,  has  lately  strongly  recommended  the 
subconjunctival  injection  of  salt  and  water  in  cases  of  dense  non- 
vascular opacities,  such  as  often  remain  after  diffuse  corneitis.  The 
strength  of  his  solution  varies  from  3j. — 5j-  of  Salt  to  3J.  of  Water.  He 
injects  this  fluid,  which  is  slightly  warmed,  very  gradually  beneath  the 
conjunctiva,  at  a  distance  of  about  one  and  a  half  or  two  lines  from 
the  edge  of  the  cornea,  around  which  it  soon  produces  considerable  che- 
motic  swelling.  It  causes  very  little  pain.  After  the  injection  he 
applies  a  compress  bandage,  and  in  the  course  of  five  or  six  hours  the 
chemosis  has  generally  entirely  disappeared  from  absorption  of  the  fluid. 
But  the  eye  now  looks  red,  and  there  is  more  or  less  conjunctival  and 
subconjunctival  irritation,  together  with  some  amount  of  ciliary 
neuralgia  and  photophobia.  These  symptoms  of  irritation  disappear 
entirely  in  the  course  of  five  or  six  days.  From  parallel  experiments 
instituted  by  Dr.  Rothmund,  in  cases  in  which  the  cornece  of  both  eyes 
were  completely  opaque,  it  seems  that  this  remedy  is  extremely  ser- 
viceable in  hastening  absorption. 

The  chalky  incrustations,  or  deposits  of  lead  upon  the  cornea,  should 
be  carefully  scraped  off  with  a  cataract  or  sickle-shaped  knife.  If  they 
are  extensive,  the  whole  need  not  be  removed,  but  only  a  portion  suffi- 
ciently large  to  uncover  the  pupil.  As  this  operation  is  sometimes  very 
painful,  it  had  better  be  done  under  chloroform,  especially  in  children. 
Afterwards,  a  little  olive  oil  or  atropine  should  be  appHed  to  the  eye. 

But  if  the  opacity  resists  all  these  remedies,  and  materially  impairs 

*  "Elinische  Monatsblatter  f.  Augenlieilkundc,"  18G6,  p.  161. 


OPACITIES  OF  THE  CORNEA.  127 

the  sight,  we  must  endeavour  to  improve  vision,  either  perhaps  by 
some  optical  arrangement,  or  by  the  formation  of  an  artificial  pupil 
opposite  a  clear  portion  of  the  cornea.  In  order  to  diminish  the 
effect  of  the  diffusion  and  irregular  refraction  of  the  rays  produced 
by  the  cloudiness,  great  advantage  is  often  experienced  from  the 
use  of  stonopaic  spectacles  (Bonders) *.  These  consist  of  an  oval 
metal  plate,  having  a  small  central  aperture.  The  effect  of  this  is  to 
permit  only  the  central  rays,  which  fall  in  the  optic  axis,  to  pass, 
whereas  all  the  peripheral,  diffused  light  is  excluded.  If  necessary, 
convex  or  concave  lenses  may  be  applied  behind  the  apparatus. 
Although  these  stenopaic  spectacles  often  answer  admirably  for  any 
employment  at  near  objects,  e.g.,  reading,  sewing,  engraving,  etc.,  they 
cannot  be  used  for  walking  about,  as  they  produce  too  great  a  con- 
traction of  the  field  of  vision. 

An  artificial  pupil  may  be  made  either  by  means  of  an  iridectomy,  or 
an  iridodesis.  If  the  opacity  is  confined  to  the  centre  of  the  cornea,  it  will 
be  best  to  perform  iridodesis,  for,  by  so  doing,  we  can  draw  the  iris  some- 
what forward  opposite  the  opacity,  and  thus  diminish  the  diffusion  of 
light  produced  by  the  latter ;  moreover,  the  apex  of  the  artificial  pupil 
will  be  opposite  the  edge  of  the  lens,  and  will  thus  obviate  the  irregular 
refraction  which  would  be  caused  if  the  periphery  of  the  lens  were 
widely  exposed  by  an  iridectomy.  But  if  the  opacity  is  more  consider- 
able, and  does  not  leave  a  wide  margin  of  clear  cornea,  the  artificial 
pupil  thus  made  would  be  insufficient,  more  especially  with  regard  to 
the  amount  of  light  admitted  into  the  eye,  and  in  such  cases  it  is  better 
to  make  an  iridectomy,  which  should,  however,  be  but  small.  If  the 
margin  of  transparent  cornea  is  very  narrow,  there  is  always  the  danger 
that  the  wound  made  in  the  performance  of  iridectomy  may  produce  a 
certain  degree  of  fresh  opacity  of  the  small  portion  of  clear  cornea  near 
it,  and  thus  militate  against  the  benefit  derived  from  the  operation.  In 
order  to  obviate  this  danger,  we  may  make  the  artificial  pupil  by  cory- 
dialysis,  which  would,  of  course,  produce  no  cloudiness  of  the  cornea 
opposite  to  the  new  pupU,  the  incision  being  made  at  another  portion  of 
the  cornea.  An  artificial  pupil  should  always  be  made  opposite  that 
portion  of  the  cornea  which  is  the  most  clear,  and  has  the  truest  curva- 
ture. The  direction  inwards,  or  slightly  downwards  and  inwards,  is  by 
far  the  best  for  optical  purposes,  for  not  only  does  the  artificial  pupil  then 
correspond  to  the  visual  line,  but  it  also  assists  better  in  the  mutual  act 
of  vision  (Gemeinshaftlicher  Sehact)  with  the  other  eye.  If  any  ante- 
rior synechia  exists,  and  its  extent  is  but  small,  it  may  be  divided  with 
the  point  of  the  broad  needle  or  iridectomy  knife,  in  the  performance  of 
iridodesis  or  iridectomy.     If  it  is  of  recent  formation  (as  after  an  incised 

*  "  Archiv.  f.  Ophthalmologic,"  i,  1,  251  ;  vide  also  Domlcrs'  "Anomalies  of 
Accommodation  and  Refraction  of  the  Eye."     New.  Syden.  Society,  p.  128. 


128  DISEASES  OF  THE  CORNEA. 

or  punctured  wotind  of  the  cornea),  the  adhesion  is  often  so  slight  that 
it  may  easily  be  detached  with  a  blunt  hook  or  a  small  spud. 

I  need  hardly  say  that  the  experiments  made  by  Nussbaum  and 
others  to  cut  a  hole  in  the  opaque  cornea  and  insert  a  piece  of  glass, 
have  completely  failed. 


9.— ARCUS  SENILIS. 

This  peculiar  marginal  opacity  of  the  cornea  is  due  to  fatty  degene- 
ration of  the  corneal  tissue,  which  generally  commences  first  in  the 
upper  portion  of  the  cornea.  It  then  shows  itself  in  the  lower,  and  the 
extremities  of  the  two  arcs  increase  more  and  more,  until  at  last  they 
meet  and  encircle  the  whole  cornea.  We  are  chiefly  indebted  to 
Mr.  Canton*  for  an  exact  and  extensive  knowledge  of  this  condition  ; 
he  has  found  that  it  generally  occurs  about  the  age  of  50,  but  that  it 
may  appear  at  a  much  earher  age,  especially  in  families  in  which  it 
appears  to  be  hereditary.  He  also  considers  that  the  arcus  senilis 
afibrds  us  the  best  indication  of  the  proneness  of  other  tissues  to  fatty 
degeneration. 

The  opacity  is  at  first  of  a  light  grey  colour,  appearing  like  a 
narrow  silvery  rim  near  the  edge  of  the  cornea,  but  not  reaching  quite 
up  to  the  latter,  being  always  divided  from  it  by  a  transparent  por- 
tion of  cornea.  At  a  later  period  the  opacity  assumes  a  denser  and 
more  creamy  tint,  and  increases  in  depth  and  width,  being  generally 
broader  above  and  below  than  at  the  sides.  It  might  be  supposed  that 
the  fatty  degeneration  of  the  corneal  tissue  would  impede  or  prevent 
the  union  of  an  incision  lying  in  this  part  of  the  cornea.  This  is,  how- 
ever, not  the  case,  for  we  find  that  a  section  carried  through  the  arcus 
senilis  heals  perfectly,  as  may  be  often  observed  in  cases  of  extraction  of 
cataract. 

10.— CONICAL  CORNEA. 

When  this  aSection  is  but  slight,  a  cursoiy  observer  may  easily 
overlook  it,  and  mistake  it,  perhaps,  for  a  case  of  myopia,  complicated 
with  weakness  of  sight  (amblyopia).  But  a  marked  case  cannot  well 
be  overlooked.  On  regarding  such  an  eye  from  the  front,  we  notice 
that  the  centre  of  the  cornea  appears  unusually  glistening  and  bright, 
as  if  a  tear-drop  were  suspended  from  it.  If  we  then  look  at  it  in 
profile,  tlie  size  and  shape  of  the  conicity  will  become  at  once  apparent. 
Sometimes  the  conicity  is  not  in  the  centre,  but  nearer  the  margin  of 
the  cornea.     But  by  means  of  the  ophthalmoscope,  even  the  slightest 

*  Vide  Mr.  Edwin  Canton's  woi-k,  "  On  tlie  Arcus  Senilis,"  London,  1863. 


CONICAL  CORNEA.  129 

cases  of  conical  cornea  maj-  be  diagnosed  with  certainty,  as  was  first 
pointed  out  by  Mr.  Bowman.*  For  this  purpose  the  mirror  alone  is  to 
be  used,  without  the  convex  lens  in  front.  On  throwing  the  light  upon 
the  cornea,  we  receive  a  bright  red  reflection  through  the  centre  of  the 
coi-nea,  which  gradually  shades  off,  and  becomes  darker  towards  the  base, 
so  that  the  central  bright  red  spot  is  surrounded  by  a  dark  zone,  which 
in  its  turn  is  again  encircled  by  a  red  ring.  If  we  throw  the  light 
upon  the  centre  of  the  cornea  at  different  angles,  the  side  of  the  cone 
opposite  to  the  light  is  darkened.  The  central  red  zone  (in  which  we 
obtain  a  reverse  image  of  the  disc,  etc.)  is  due  to  the  reflection  of  the 
fundus  through  the  central  conical  portion  of  the  cornea,  and  the 
outer  red  ring  to  the  reflection  through  the  normal  peripheral  portion 
of  the  cornea.  The  dark  zone  between  the  two  is,  according  to  Knapp,t 
due  to  the  difiusion  and  complete  reflection  of  the  rays  of  light  at  the 
base  of  the  cone,  where  it  passes  over  into  the  normal  curvature  of  the 
cornea. 

On  the  ophthalmoscoj)ic  examination  of  the  fundus  of  an  eye 
afiected  with  conical  cornea,  we  notice  a  considerable  parallax  on 
moving  the  convex  lens  in  front  of  the  patient's  eye.  J  In  this  way  we 
can  produce  a  distortion  and  displacement  of  a  certain  portion  of  the 
disc  and  retinal  vessels,  whilst  the  other  part  of  the  disc  remains 
immovable,  just  as  occurs  in  glaucomatous  excavation  of  the  optic 
nerve. 

Even  in  slight  cases  of  conical  cornea,  the  patients  already  complain 
of  considerable,  and  often  great  impairment  of  sight.  On  account  of 
the  conicity  of  the  central  portion  of  the  cornea,  the  antero -posterior 
axis  is  increased  in  length,  and  hence  the  eye  has  becon:ie  more  or  less 
myopic,  and  the  patient  consequently  holds  small  objects  (as  in  reading, 
etc.)  very  close  to  the  eye.  But  the  impairment  of  sight  is  chiefly 
due  to  the  astigmatism  caused  by  the  irregular  cuiwature  of  the  cornea, 
which  gives  rise  to  great  distortion  and  confusion  of  the  retinal  images. 
Concave  spherical  lenses,  therefore,  generally  produce  but  slight 
improvement,  but  some  benefit  is  occasionally  derived  from  cylindrical 
glasses,  although  the  astigmatism  is  as  a  rule  too  irregular  to  admit 
of  much  correction.  More  improvement  is  found  from  the  use  of  a 
circular  or  slit-shaped  stenopaic  apparatus,  fitted,  perhaps,  with  a 
suitable  concave  lens,  as  this  diminishes  the  circles  of  difiusion  upon 
the  retina  by  cutting  off  the  peripheral  rays  of  light.  We  often  notice 
that  the  patients  endeavour  to  accomplish  this  for  themselves  by  nipping 
their  eyelids  together,  so  as  to   change  the  palpebral  aperture  into  a 

*  "  Royal  Lond.  Ophth.  Hosp.  Ecports,"  vol.  ii,  p.  151. 
t  "  Klinisclie  Monatsbliit.ter,"  ISGl,  313. 

X  Dontlers,  "  Archiv.  f.  Oplith.,"  7,  199 ;  also  Donders,  "  On  the  Anomalies  of 
Accommodation  and  Refraction,"  551.     New  Sydenham  Society. 

K 


130  DISEASES   OF   THE   CORNEA. 

narrow  slit.  After  the  disease  has  existed  a  certain  time,  and  reached  a 
high  degree  of  development,  the  apex  of  the  cone  often  becomes  opaque, 
and  thus  the  sight  is  still  more  deteriorated. 

The  bulging  forward  of  the  cornea  is  not  due  to  an  increase  in  the 
intra-ocular  tension  (which  is  indeed  rather  slackened),  but  to  a  dimi- 
nution in  the  power  of  resistance  of  the  cornea,  and  as  this  bulging 
increases,  the  portion  of  cornea  embraced  in  it  becomes  thinner  and 
thinner.  It  is  an  interesting  fact,  that  however  attenuated  the  apex 
may  become,  it  never  gives  way,  except  through  an  accidental  injuiy. 
Mr.  Bowman  thinks  that  the  reason  of  this  is,  that  "  as  the  cornea 
becomes  thinner,  the  escape  of  the  aqueous  humour  by  exosmose  is 
facilitated,  and  thus  the  internal  pressure  is  reduced,  so  as  to  be  no 
longer  in  excess  of  the  dirainished  resisting  power  of  the  cornea.  A 
balance  is  established  like  that  of  health,  only  that  there  is  a  more  than 
ordinary  outflow  of  the  aqueous  humour  by  transudation  through  the 
cornea.  This  accords  with  my  previous  observation,  as  to  such  eyes 
being  rather  unduly  soft." 

The  progress  of  the  disease  is  generally  very  slow.  It  may  become 
stationary  at  any  point,  stopping  short  when  the  conicity  is  still  but 
slight,  or  going  on  until  it  is  very  considerable  and  the  apex  has 
become  clouded.  It  generally  sooner  or  later  attacks  both  eyes.  It 
occurs  frequently,  but  not  always,  in  persons  of  a  delicate  constitution, 
and  commences  chiefly  between  the  ages  of  15  and  30.  Mr.  Bowman 
has  observed  a  very  few  cases  in  which  it  occurred  in  more  than  one 
member  of  the  same  family.  Any  considerable  and  protracted  use  or 
straining  of  the  eye  in  reading,  sewing,  etc.,  will  tend  to  increase  its 
development  and  produce  local  irritation  and  congestion. 

Innumerable  remedies  have  been  suggested  and  tried  for  the  relief 
and  cure  of  conical  cornea,  but  almost  all  of  them  without  success.  If 
the  patient  is  in  delicate  health,  tonics  and  a  nutritious  diet  with  plenty 
of  fresh  air  and  exercise,  should  be  prescribed,  and  the  use  of  the  eyes 
for  reading,  etc.,  should  be  forbidden  if  both  are  afiected.  In  order  to 
neutralise  the  myopia  produced  by  the  conicity  of  the  cornea.  Sir 
W.  Adams  removed  the  lens.  Mr.  Wardrop  recommended  frequent 
tapping  of  tbe  anterior  chamber.  Mr.  Tyrrel  was  the  first  to  make  an 
artificial  pupil  in  this  disease,  and  this  is  the  treatment  which  has 
hitherto  proved  most  successful.  The  purpose  we  have  in  view  in 
making  an  artificial  pupil  is  twofold :  1st.  To  improve  vision  by 
making  a  pupil  opposite  a  portion  of  the  cornea  which  has  retained 
its  normal  curvature ;  2nd.  To  arrest  the  progress  of  the  disease,  and, 
if  possible,  to  cause  it  to  retrograde  somewhat  by  diminishing  the 
intra-ocular  pressure. 

The  artificial  pupil  may  be  made  either  by  an  iridectomy  or  an 
iridodesis.      By   the   former  operation  we  certainly  bring  the  pupil 


CONICAL   CORNEA.  131 

opposite  a  marginal  portion  of  the  cornea,  but  tliere  is  this  disadvantage, 
that  the  original  pupil  remains  opposite  the  conicity,  and  therefore  the 
rays  which  pass  through  it  are  diffused  and  irregularly  refracted,  and 
thus  confuse  the  retinal  image  and  diminish  its  distinctness  ;  whereas, 
by  means  of  an  iridodesis  we  can  di'aw  the  ii-is  well  forward  towards  the 
incision,  and  thus  displace  the  pupil  towards  a  portion  of  the  cornea, 
Avhich  is  less  irregularly  curved,  and  bring  the  iris  opposite  the  cone. 
The  incision  should  be  made  slightly  in  the  sclerotic,  so  that  the  plane  of 
the  iris  may  not  be  moved  away  ft'om  the  lens.  The  best  du^ection  for 
the  iridodesis  is  slightly  dowoi wards  and  inwards.  In  order  to  obtain  the 
advantages  which  are  derived  from  a  slit-shaped  stenopaic  apparatus, 
Mr.  Bowman  has  made  a  double  iridodesis,  so  that  an  oblong  slit- shaped 
pupil  is  obtained.  This  may  be  made  either  vertical  or  horizontal. 
In  the  former  case,  we  have  the  advantage  that  a  considerable  portion 
of  the  angles  of  the  slit  is  covered  by  the  lids,  which  renders  it  much 
less  unsightly,  more  especially  if  the  irides  are  light  in  colour,  than  the 
horizontal  slit,  which  gives  the  appearance  of  a  cat's-eye.  The  operation 
should  not  be  performed  in  opposite  directions  at  the  same  sitting,  as 
.  the  point  first  tied  is  apt  to  yield  and  be  drawn  into  the  anterior 
chamber  again,  when  the  iris  is  drawn  towards  the  opposite  incision. 
It  is  best  to  make  the  second  iridodesis  about  eight  or  ten  days  after 
the  first.  The  incision  should  be  made  in  the  sclerotic  so  as  to  retain 
the  normal  plane  of  the  iris. 

Not  only  does  this  operation  produce  a  beneficial  effect  in  an  optical 
point  of  view,  but  it  also  sometimes  causes  a  considerable  diminution 
in  the  bulge  of  the  cornea  and  the  progress  of  the  disease.  At  present 
it  is  very  difficult  to  decide  upon  the  point  as  to  which  operation  is 
really  the  best,  as  the  results  have  varied  considerable.  For  instance, 
in  some  cases  benefit  has  been  produced  in  the  sight  by  the  second 
iridodesis,  whereas  in  others  again  this  has  not  been  the  case.  The  im- 
provement is,  however,  never  so  conspicuous  as  after  the  first  operation. 
My  own  experience  rather  tends  to  the  opinion  that  on  the  whole  the 
progress  of  the  disease  is  most  arrested  and  the  bulging  of  the  cornea 
most  diminished  by  an  iridectomy.  Care  must,  however,  be  taken  to 
make  it  only  moderate  in  size,  and  perhaps  slightly  upwards  and  inwards, 
so  that  a  part  of  the  base  of  the  artificial  pupil  may  be  covered  by 
the  upper  lid.  In  slight  cases,  in  which  the  conicity  is  either  almost 
stationary  or  but  very  slowly  progressive,  I  think  iridodesis  is  indicated, 
whereas  if  it  is  considerable  and  markedly  progressive,  an  iridectomy  is 
to  be  preferred. 

Von  Graefe  has  lately  published  a  very  interesting  case  of  conical 

cornea,  in  which  he  produced  ulceration  of  the  apex  of  the  cone,  and 

subsequent  contraction  and  flattening  of  the  cicatrix.*  The  fact  that  the 

*  ''  A.  f.  O.,"  12,  2,  215.     More  recently  Von  Graefe  has  published  an  elaborate 

k2 


132  DISEASES   OF   THE  CORNEA. 

cicatricial  contraction  whicli  follows  extensive  ulcers  or  infiltrations  of 
the  cornea  always  proclnces  a  certain  degree  of  diminution  or  flattening 
of  tlie  curvature  of  tlie  cornea,  led  Von  Graefe  to  the  idea  that  a  similar 
efiuct  might  be  brought  about  in  severe  cases  of  conical  cornea,  by  the 
artificial  production  of  a  little  ulcer.  The  operation  is  to  be  performed 
in  the  following  manner  : — The  point  of  a  very  small  knife,  made  of  the 
shape  of  Von  Graefe's  narrow  cataract  knife,  but  smaller  in  size,  is  to  be 
passed  into  the  middle  layers  of  the  cornea,  just  at  the  apex  of  the 
cone,  to  the  extent  of  about  a  line,  and  then  brought  out  again  ;  so  that 
a  very  small  superficial  flap  may  be  formed,  which  is  then  to  be  seized 
with  a  very  fine  pair  of  forceps  and  snipped  oflF  at  its  base  with  a  pair  of 
curved  scissors,  thus  leaving  a  superficial  gap  at  this  point.  Great  care 
must  be  taken  that  the  knife  does  not  penetrate  the  cornea,  of  which 
there  is  the  greater  risk  on  account  of  the  extreme  tenuity  of  the 
cornea  at  the  apex  of  the  cone.  Should,  however,  perforation  occur,  the 
operation  should  be  postponed  for  a  few  days,  until  the  aperture  is  closed. 
The  day  after  the  operation,  the  floor  of  the  gap  is  to  be  lightly  touched, 
at  two  or  three  points,  with  a  finely  pointed  crayon  of  mitigated  nitrate 
of  silver  (nitrate  of  silver  1  part,  nitrate  of  potash  2  parts),  the  efiect  of 
the  cauterization  being  at  once  neutralized  by  the  application  of  salt 
and  water.  The  application  of  the  caustic  is  to  be  repeated  at  intervals 
of  from  three  to  six  days,  until  a  slight  faintly- yellowish  infiltration  is 
formed,  with  but  a  moderate  degree  of  pericorneal  injection,  when  we 
may  consider  the  efiect  as  sufficient,  and  simply  apply  atropine  to  the 
eye  and  guard  it  against  exposure.  The  catiterization  generally  pro- 
duces but  very  little  irritation.  Should  the  infiltration  show  a  tendency 
to  assume  the  character  of  a  perforating  ulcer,  the  compress  bandage 
must  be  employed  alternately  with  warm  aromatic  fomentations,  and  it 
may  even  be  necessary  to  perform  paracentesis.  The  improvement  of 
tlie  sight  will  not  be  at  once  apparent,  indeed  at  first  it  may  even  be 
deteriorated,  but  at  the  end  of  five  or  six  weeks,  when  the  infiltration 
begins  to  contract,  it  rapidly  increases,  the  little  cicatricial  opacity  gra- 
daally  diminishes  in  size  and  density,  and  leaves  the  sight  greatly  im- 
proved. Von  Graefe  has  performed  this  operation  with  great  success  in 
several  cases  of  severe  conical  cornea,  and  has  gained  much  better 
results  than  from  the  formation  of  an  artificial  pupil. 

11.— KERATO-GLOBUS  (HrDROPHTHALMIA  ANTERIOR, 
HYDROPS  OF  THE  ANTERIOR  CHAMBER). 

This  disease  is  characterised  by  a  uniform  spherical  bulging  of  the 
whole   cornea,  so   that   it  is  increased   in   size   in  all  its  diameters. 

and  inlevcsting  paper  upon  this  subject  in  Ihe  "Berliner  Klinisclic  Woclienschrift," 
18G8,  No.  23. 


KERATO-GLOBUS.  133 

Generally,  however,  tliis  increase  in  size  is  not  confined  to  the  cornea, 
but  extends  to  the  neighbouring  portion  of  the  sclerotic.  The  aug- 
mentation in  the  size  of  the  anterior  half  of  the  eyeball  is  often  so  con- 
siderable, that  the  ej'c  protrudes  between  the  palpebral  aperture,  and 
prevents  the  easy  closiu'e  of  the  eyelids.  On  account  of  the  peculiar 
staring  appearance  which  this  gives  to  the  eye,  the  disease  has  also 
been  termed  '■'•huphilialmos.'" 

The  cornea  may  either  remain  transparent  or  become  slightly 
opaque  near  the  periphery ;  in  other  cases  the  cloudiness  may  be  more 
considerable,  and  extend  over  the  greater  portion  of  the  surface  of  the 
cornea.  The  anterior  portion  of  the  sclerotic  is  much  thinned  and  of 
a  blue  tint,  which  is  due  to  a  shining  through  of  the  choroid.  The 
size  of  the  anterior  chamber  is  much  increased,  both  in  depth  and 
circumference.  The  aqueous  humour  is  generally  clear.  The  iris  is 
also  enlarged,  and  the  fibres  near  its  ciliary  margin  are  stretched  and 
opened  up ;  the  pupil  is  generally  somewhat  dilated  and  sluggish,  and 
perhaps  here  and  there  adherent  to  the  capsule.  The  iris  is  often 
somewhat  cupped  back,  Avhich  increases  still  more  the  depth  of  the 
anterior  chamber,  and  it  may  also  be  tremulous,  which  may  be  either 
due  to  dislocation  of  the  lens,  caused  by  a  stretching  and  giving  way 
of  its  suspensory  ligament ;  or  to  the  iris  being  no  longer  in  contact 
with  the  anterior  surface  of  the  lens,  but  divided  from  it  by  a  collec- 
tion of  fluid  in  the  posterior  chamber.  Sometimes,  however,  the  iris 
is  bulged  forwards.  The  state  of  the  sight  varies  very  considerably. 
In  some  cases  the  patient  can  still  decipher  moderate  sized  print ;  in 
others  it  is  greatly  impaired,  which  may  be  due  to  the  ojiacity  of  the 
cornea,  or  to  inflammation  of  the  deeper  tunics  of  the  eye. 

The  disease  does  not  appear  to  be  due  to  an  increased  secretion  of 
the  aqueous  humour,  but  to  a  thinning  and  diminution  in  the  jwwer  of 
resistance  of  the  cornea,  following  generally  upon  severe  and  extensive 
inflammations  of  the  cornea,  as,  for  instance,  vascular  corneitis  or 
pannus.  The  opacity  may  afterwards  disappear,  but  the  bulging  re- 
mains, and  even  gradually  augments.  Treatment,  unfortunately,  is 
but  too  often  of  little  avail.  The  most  is  to  be  expected  from  a  large 
iridectomy.  I  have  lately  seen  a  case  under  Mr.  Critchett's  care  in 
which  this  operation  was  performed  with  much  benefit.  The  patient's 
general  health  should  be  strengthened,  and  the  eyes  be  but  moderately 
employed.  If  the  protrusion  is  very  considerable,  the  cornea  opaque, 
and  the  sight  almost  entirely  gone,  an  operation  for  staphyloma  may 
be  indicated,  not  only  for  the  sake  of  appearance  of  the  eye,  but  also 
to  alleviate  the  inconvenience  and  constant  irritation  kept  up  by  the 
incomplete  closure  of  the  eyelids. 


134  DISEASES  OF   THE   CORNEA. 


12.— STAPHYLOMA  OF  THE  CORNEA  AND  IRIS. 

"We  have  already  seen  that  when  an  tilcer  of  the  cornea  causes 
perforation  of  the  latter,  the  aqueous  humour  flows  off,  the  iris  falls 
forward,  and  may  become  adlierent  to  the  cornea.  If  the  perforation 
is  but  of  slight  extent,  an  anterior  synechia  will  be  produced, 
without  perhaps  any  bulging  of  the  cornea  at  this  point.  But  if  the 
opening  is  large,  a  considerable  portion  of  iris  will  fall  against  or  into 
the  gap,  and  perhaps  protrude  through  it,  giving  rise  to  a  more  or  less 
extensive  prolapse.  This  is  soon  covered  with  a  layer  of  lymph,  which 
becomes  organized,  gradually  assumes  a  cicatricial  character,  and  re- 
places the  cornea  at  this  point,  to  which  it  may  indeed  bear  a  certain 
outward  resemblance.  It  is,  however,  much  weaker  and  less  elastic,  so 
that  it  readily  yields  to  the  intra-ocular  pressure,  gradually  bulges  for- 
ward, and  gives  rise  to  a  partial  staphyloma.  If  the  latter  is  situated 
at  the  margin  of  the  cornea,  the  pupil  may  remain  partially  or  entirely 
free,  and  a  certain  amount  of  sight  be  preserved.  But  if  the  prolapse 
occurs  in  the  centre,  the  whole  pupil  will  be  involved.  A  partial 
staphyloma  may  gradually  increase  in  size  until  it  implicates  the  sur- 
rounding cornea  to  a  considerable  extent,  and  if  the  perforation  was 
originally  of  large  size,  it  may,  finally,  even  involve  the  whole  cornea, 
and  become  changed  into  a  total  staphyloma.  When  the  projection 
has  become  at  all  considerable,  so  as  to  protrude  somewhat  between  the 
lids,  its  exposure  to  the  action  of  external  irritants  is  apt  to  produce 
occasional  inflammatory  exacerbations,  which  tend  to  cause  a  still 
greater  increase  in  the  size  of  the  staphyloma. 

The  most  frequent  causes  of  partial  staphyloma  are  sloughs  and 
ulcers  of  the  cornea,  wounds  and  injuries,  and  also  certain  operations 
upon  the  eye,  as  for  instance,  flap  extraction,  which  may  be  followed 
by  considerable  prolapse  of  the  iris  and  the  formation  of  a  partial 
staphyloma. 

No  time  should  be  allowed  to  elapse  before  the  tendency  to  staphy- 
loma is  checked.  Thus  if  a  prolapse  of  the  iris  has  occurred,  it  should 
be  treated  at  once  by  the  proper  remedies.  The  best  treatment  for 
partial  staphyloma  is  undoubtedly  by  iridectomy,  as  this,  by  diminish- 
ing the  intra-ocular  pressure,  not  only  prevents  the  increase  of  the 
bulging,  but  generally  also  causes  it  to  decrease  in  size.  The  artificial 
pupil  should  be  made  opposite  to  the  most  transparent  portion  of 
cornea.  I  must  here  again  mention  the  very  important  fact  that  cases  of 
partial  or  complete  staphyloma  are  sometimes  accompanied  by  marked 
increase  of  tension,  so  that  the  eye  is  in  a  glaucomatous  condition,  and 
the  degree  of  impairment  of  vision  quite  disproportionate  to  the  amount 
of  staphyloma  and  opacity  of  the  cornea.     In  such  cases  there  will  be 


TOTAL   STAPHYLOMA   OF   THE   CORNEA   AND   IRIS.  13/5 

increase  of  tension,  accompanied  perhaps  by  contraction  of  the  field, 
eccentric  fixation,  and  excavation  of  the  optic  nerve.  In  all  cases  of 
staphyloma  the  degree  of  tension,  the  state  of  the  sight,  and  of  the  field 
of  vision  must  therefore  be  carefully  watched,  and  an  iridectomy  must 
be  on  no  account  delayed  if  symptoms  of  glaucoma  supervene.  I  think 
this  treatment  of  partial  staphyloma  by  iridectomy  greatly  preferable 
to  that  which  was  formerly  much  in  vogue,  viz. ,  the  touching  the  pro- 
trusion with  nitrate  of  silver,  and  thus  changing  it  into  an  ulcer  which, 
on  cicatrizing,  would  produce  a  flattening  and  shrinking  of  the  staphylo- 
matous  tissue.  This  is  apt  to  set  up  considerable  irritation,  and  proves 
far  less  efficacious  than  an  iridectomy.  Partial  abscission  may  also  be 
performed  by  a  modification  of  Critchett's  operation. 

13.— TOTAL  STAPHYLOMA  OF  THE  CORNEA  AND  IRIS. 

This  only  occm^s  in  cases  in  which  there  has  been  an  almost  total 
destruction  of  the  cornea  by  sloughing  or  ulceration.  Its  shape  is 
generally  spherical,  although  occasionally  it  may  be  conical.  The  neigh- 
bouring portion  of  the  sclerotic  mostly  becomes  imphcated  in  the 
process,  and  the  staphyloma  may,  in  time,  involve  the  anterior  half  of 
the  eyeball.  The  lens  may  either  have  escaped  at  the  time  of  the  per- 
foration, or  have  remained  behind,  in  which  case  it  often  becomes 
opaque.  Its  position  within  the  eye  varies ;  it  generally  lies  in  close 
contact  with  the  ii'is  and  the  cicatricial  tissue,  to  which  it  becomes 
adherent ;  it  may,  however,  be  separated  from  the  iris  by  a  considerable 
amount  of  aqueous  humotu',  which  forms  a  large  posterior  chamber  ;  or, 
again,  it  may  have  become  detached  from  the  suspensory  ligament  and 
sink  down  into  the  vitreous  humour. 

The  presence  or  absence  of  the  lens  after  an  extensive  perforation 
of  the  cornea  exerts  great  influence  upon  the  formation  of  a  staphyloma. 
If  the  lens  escaped  at  the  giving  way  of  the  cornea,  a  firm  cicatrix  is 
formed,  which  will  generally  resist  the  intra- ocular  pressure,  and  not 
bulge  forward,  but  will  often  become  consolidated,  contract,  and  lead, 
perhaps,  to  a  certain  degree  of  shrinking  of  the  globe.  It  is  different, 
however,  if  the  lens  has  remained  within  the  eye,  for  it  then  bulges 
forward,  and  presses  upon  the  newly  formed  cicatricial  tissue,  which 
gradually  yields  and  becomes  staphylomatous.  If,  therefore,  a  case  of 
extensive  perforation  of  the  cornea,  with  a  tendency  to  staphyloma,  is 
seen  at  an  early  stage,  and  the  lens  is  found  pressing  against  the 
cicatrix,  it  is  best  to  remove  it  at  once,  so  as  to  allow  the  cicatrix  to 
become  firm  and  consolidated.  The  lens  may  be  removed  by  making 
an  incision  into  the  staphyloma  with  Graefe's  cataract  knife,  di\ading 
the  capsule,  and  allowing  the  lens  to  escape.  Or,  it  may  be  done 
according  to  the  following  proceeding  of  Mr.  Bowman,  which  I  have 


136 


DISEASES   OF   THE   CORNEA. 


seen  answer  remarkably  well  in  several  cases.  He  passes  a  broad  needle 
througli  the  staphyloma  into  the  lens,  and  breaks  this  freely  up.  The 
needle  having  been  withdrawn,  a  curette  is  passed  through  the  same 
opening,  and  the  soft  lens  matter  allowed  to  escape.  The  breaking  up 
of  the  lens  may  be  repeated  at  intervals  of  a  few  days.  The  staphylo- 
matous  protrusion  -will  gradually  subside,  the  cicatrix  will  become  firm 
and  consolidated,  and  the  eye  perhaps  shrink  somewhat.  When  all 
symptoms  of  irritation  have  subsided,  an  artificial  eye  may  often  be 
worn  without  the  necessity  of  any  further  operation. 

As  we  cannot  restore  any  sight  in  cases  of  total  staphyloma,  the 
object  of  our  treatment  must  be  to  remove  the  protrusion,  so  as  to  fi-ee 
the  patient  from  the  pain  and  inconvenience  which  generally  attend 
this  disease,  and  also  to  improve  the  personal  appearance  and  pei'mit  of 
the  adaptation  of  an  artificial  eye.  There  are  numerous  modes  of 
operating  for  staphyloma,  of  which  the  following  only  require  men- 
tion : — 1,  Excision.  2,  Mr.  Critchett's  operation  of  abscission.  3, 
Graefe's  seton  operation.     4,  Borelli's  operation. 

1.  Excision. — This  is  best  performed  in  the  following  manner.  The 
point  of  a  cataract  knife  (the  edge  of  which  is  turned  downwards,  as  in 

fig.  10),  is  to  be  passed  into 
the  sclerotic,  near  the  edge  of 
the  staphyloma,  and  somewhat 
above  its  horizontal  diameter, 
so  that  about  -I  of  the  staphy- 
loma may  be  included  in  the 
incision.  The  blade  of  the 
knife  is  to  be  carried  on  paral- 
lel to  the  base  of  the  tumour, 
until  its  point  makes  its  exit 
at  the  opposite  side,  at  a  spot 
corresponding  to  the  punc- 
ture. The  knife  should  then 
be  pushed  slowly  on,  until  it 
has  cut  its  way  out  and  divided 
the  lower  -f  of  the  staphy- 
loma, by  a  large  flap-shaped 
incision.  The  remaining  portion  is  then  to  be  divided  by  the  aid  of 
a  pair  of  scissors.  A  bandage  is  then  to  be  applied,  either  together  with 
water  dressing  or  a  simple  pledget  of  lint.  Lymph  will  be  efi'used  from 
the  edges  of  the  incision,  and  a  more  or  less  firm  cicatrix  result ;  the 
eyeball  will  shrink  somewhat,  but  leave  perhaps  a  tolerable  good  stump 
for  the  application  of  the  artificial  eye.  The  result  of  the  operation  is 
not,  however,  always  so  favourable.  A  considerable  gush  of  vitreous 
humour  may  follow  upon  the  excision  of  the  anterior  portion  of  the  eye, 


After  Stellwag. 


TOTAL  STArHYLOMA  OF  THE  CORNEA  AND  IRIS. 


137 


and  intra-ocular  hocmoiThage  ensue.  Or,  again,  suppuration  of  the  eye 
may  take  place,  accompanied,  perhaps,  by  very  violent  pain  and  inflam- 
mation. The  eyeball  then  shrinks  and  dwindles  down,  leaving  but  a 
very  small  and  inefficient  stump,  with  a  slight  degree  of  movement,  for 
the  application  of  an  artificial  eye.  To  obviate  these  disadvantages, 
Mr.  Critchett  has  employed  the  following  ingenious  and  valuable 
operation  of  abscission,  which  leaves  an  excellent,  large  moveable 
stump. 

2.  Mr.  Critchett's*  operation  of  abscission  is  to  be  performed  thus : 
"  The  patient  being  placed  under  the  influence  of  chloroform,  the  staphy- 
loma is  freely  exposed  by  means  of  a  wire  speculum ;  a  series  of  four  or 
five  rather  small  needles,  with  a  semicircular  curve,  are  passed  through 
the  mass,  about  equi-distant  from  each  other,  and  at  such  points  as  thf 
lines  of  incisions  are  intended  to  traverse  (fig.  11).     These  needles  arc 

Fig.  11. 


After  Lawsou. 


left  in  this  position,  with  both  extremities  protruding  to  an  equal 
extent  from  the  staphyloma.  The  advantages  gained  by  this  part  of 
the  proceeding  are: — 1.  That  a  small  quantity  of  the  fluid  parts  of 
the  distended  globe  escapes,  thus  diminishing  pressure,  and  preventing 
a  sudden  gush  of  the  contents,  when  the  anterior  part  is  removed. 
2.  That  the  points  of  emergence  indicate  the  lines  of  incision.  3.  That 
the  presence  of  the  needles  prevents,  or  rather  restrains,  to  some  extent, 
the  escape  of  the  lens  and  vitreous  humour,  after  the  anterior  part  of 
the  staphyloma  has  been  removed.  The  next  stage  of  the  proceeding 
is  to  remove  the  anterior  part  of  the  staphyloma.  This  requires  some 
judgment  and  modification  in  size  and  form,  in  accordance  with  the 
extent  of  the  enlargement,  so  as  to  leave  a  convenient  bulb.  My 
usual  plan  is  to  make  an  opening  in  the  sclerotic,  about  two  lines  in 

*  "  Roy.  Loud.  Ophth.  Hosp.  Reports,"  iv,  1. 


138 


DISEASES   OF   THE   CORNEA. 


extent,  just  anterior  to  the  tendinous  insertion  of  the  external  rectus, 
made  with  a  Beer's  knife.  Into  this  opening  I  insert  a  pair  of  small 
probe-pointed  scissors,  and  cut  out  an  elliptical  piece,  just  within  the 
points  where  the  needles  have  entered  and  emerged.  The  needles, 
armed  with  fine  black  silk,  are  then  drawn  through  each  in  its  turn, 
and  the  sutures  are  carefully  tied  so  as  to  approximate  as  closely  as 
possible  the  divided  edges  of  the  sclerotic  and  conjunctiva  (fig.  12). 

Fig.  12. 


After  Lawson. 


The  operation  is  now  finished ;  the  speculum  may  be  removed  so  as 
to  allow  the  lids  to  close,  and  wet  lint  may  be  applied  to  keep  the  parts 
cool.  In  a  large  majority  of  cases,  union  of  the  divided  edges  takes 
place  by  the  first  intention"  .  .  .  .  "I  generally  leave  the  sutures 
in  for  some  weeks.  Sometimes  they  come  away  spontaneously,  and 
when  this  is  not  the  case,  they  may  readily  be  removed  after  all  irrita- 
tion has  passed  away,  and  after  firm  union  has  taken  place.  If  the 
case  be  examined  three  or  four  months  after  the  operation,  a  moveable 
bulb  is  seen  with  a  flattened  anterior  surface,  traversed  by  a  white  line 
of  cicatrix,  and  having  rather  a  prominent  external  angle.  Upon  this 
an  artificial  eye  can  be  readily  adapted,  which  moves  to  a  greater  extent 
than  I  have  observed  previous  to  adoption  of  my  present  method." 

Care  must  be  taken  in  making  the  incision,  so  to  slope  and  bevel  off 
the  angles  that  the  lips  of  the  wound  here  fit  very  accurately  and 
neatly,  otherwise  an  awkward  pucker  may  be  left  at  these  points, 
which  will  interfere  materially  with  the  comfort  of  wearing  an  artificial 
eye.  It  is  always  best,  except  perhaps  in  young  children,  or  where 
the  staphyloma  is  small,  to  employ  five  sutures,  in  order  that  too  great 
an  interval  may  not  be  left  between  them,  for  if  this  be  the  case,  beads 
of  vitreous  will  protrude,  become  covered  with  granulations  and  sup- 
purate somewhat.  My  experience  of  Mr.  Critchett's  operation  has 
certainly  been  most  favourable,  and  I  can  entirely  endorse  his  state- 


TOTAL   STAPHYLOMA  OF   THE   CORNEA  AND   IRIS.  139 

ment,  that  we  gain  by  it  a  better  and  more  perfectly  moveable  stump 
for  an  artificial  eye,  than  by  any  other  operation.  I  do  not,  however, 
think  it  indicated  in  those  cases  in  which  the  disease  is  not  confined  to 
the  anterior  portion  of  the  eyeball,  but  the  inflammation  has  extended 
to  the  retina  and  choroid.  For  in  such  cases,  the  operation  is  not  only 
often  followed  by  perhaps  immediate  and  severe  intra-ocular  hoemorrhage 
leading  to  suppuration  of  the  globe,  but  we  leave  behind  a  part  of  the 
diseased  structure,  which  may  not  only  become  again  inflamed,  but, 
what  is  still  more  to  be  dreaded,  be  the  cause  of  sympathetic  inflam- 
mation in  the  other  eye.  In  all  such  cases,  it  is  therefore  undoubtedly 
by  far  the  safest  plan  to  remove  the  whole  eyeball,  as  this  frees  us 
from  all  fear  of  sympathetic  ophthalmia.  If  the  patient  is  in  good 
circumstances,  and  is  so  situated  that  he  can  at  once  apply  to  a 
surgeon  if  the  stump  becomes  inflamed,  or  symptoms  of  sympathetic 
irritation  show  themselves,  and  if  he  is  extremely  anxious  about  his 
personal  appearance,  abscission  may  be  performed,  otherwise  it  is 
safest  to  remove  the  staph yloraatous  eye  altogether.  I  must  here 
state,  that  in  the  "  Dublin  Quarterly  Journal  of  Medical  Science  "  for 
1847,  Vol.  iii.,  p.  242,  Mr.  (now  Sir  WiUiam)  Wilde,  drew  attention 
to  a  new  operation  which  he  had  devised  for  the  removal  of  staphyloma. 
This  consisted  in  the  introduction  of  a  curved  needle  tlrrough  the  base 
of  the  staphyloma,  then  removing  the  conical  projection  with  a  cataract 
knife  and  scissors,  drawing  the  needle  through,  and  tying  the  ligature. 
Sir  WiUiam  Wilde  subsequently  sometimes  employed  several  ligatm'es. 
3.  Von  Q-roxfe's*  operation  by  seton  consists  in  passing  a  double  thread 
parallel  to  the  cornea,  thi^ough  the  coats  of  the  eyeball  (but  notwhere  they 
are  thinned)  and  the  vitreous  humour,  so  as  to  include  them  within  a 
suture  to  an  extent  of  four  or  five  lines.  The  threads  are  not  to  be 
tied  tightly,  but  left  in  a  loose  loop,  and  their  ends  are  to  be  snipped 
ofi"  close  to  the  knot.  A  light  compress  is  to  be  applied  to  the  lids. 
Withia  16  to  32  hours,  acute  symptoms  of  suppm'ative  choroiditis 
generally  supervene,  accompanied  by  subconjunctival  chemosis,  slight 
immobihty  in  the  lateral  movements  of  the  eye,  and  perhaps  a  certain 
degree  of  protrusion  of  the  globe.  The  threads  are  then  to  be  removed, 
and  warm  camomile  or  poppy  fomentations  should  be  applied  to  alle- 
viate the  paui.  The  eyeball  after  a  time  becomes  shrunk  and  atrophied. 
I  have  seen  one  case  successfully  treated  by  Mr.  Bowman  in  a  some- 
what similar  manner.  The  threads  were,  however,  left  in  for  some  time 
and  occasionally  moved.  There  were  no  severe  symptoms  of  inflam- 
mation, and  the  eye  gradually  diminished  to  about  half  its  original 
size,  and  an  artificial  eye  is  now  worn  with  comfort.  The  great  advan- 
tage of  this  proceeding  is  that  there  is  no  tendency   to   sympathetic 

*  "  Archiv.  f.  Ophthalmologic,"  ix,  2,  105. 


140  DISEASES   OF   THE  CORNEA. 

inflammation,  which  appears  never  to  ensue  upon  suppurative  choroi- 
ditis. 

4.  Dr.  Borelli  transfixes  the  staphyloma  by  two  needles,  which  are 
passed  through  the  base  of  the  protrusion,  so  as  to  cross  each  other  at 
right  angles.  The  one  is  entered  at  the  temporal  side,  midway  between 
the  vertical  and  horizontal  meridian  of  the  cornea,  passed  beneath  the 
tumour,  and  brought  out  at  a  corresponding  point  at  the  opposite  side. 
This  pin  may  be  entered  either  above  or  below  the  horizontal  meridian, 
as  appears  most  convenient  to  the  operator.  The  second  pin  is  then  to  be 
introduced  at  right  angles  to  the  first,  so  that  they  form  a  cross  (  x  ).  A 
thread  is  then  passed  round  the  staphyloma  behind  the  pins,  and  tightly 
tied  ;  the  ends  may  be  twisted  and  fastened  to  the  cheek.  Simple 
cerate  dressing  and  a  compress  bandage  should  be  applied.  At  the 
end  of  the  third  day  the  protrusion,  together  with  the  pins  and  thread, 
ai'e  generally  found  to  be  detached,  and  on  the  eighth  or  ninth  day  the 
wound  is  firmly  cicatrized.  If  the  staphyloma  is  total  or  large,  as  little 
as  possible  should  be  included  between  the  pins,  and  the  threads  should 
not  be  drawn  too  tight,  lest  the  strangulated  portion  might  give  way, 
or  severe  ophthalmitis  be  set  up.  In  partial  staphyloma  its  whole  base 
should  be  included,  and  the  threads  tied  close  and  tight  within  the  re- 
maining cornea.  I  have  had  no  personal  experience  of  this  operation,  but 
it  has  been  strongly  re  commended  by  several  eminent  surgeons,  more  espe- 
cially for  partial  staphyloma,  as  it  leaves  a  good  portion  of  clear  cornea 
behind  wliich  to  make  an  artificial  pupil.  The  operation  is  almost  free 
from  danger,  and  leaves,  at  the  worst,  a  firm,  moveable  stump  for  an 
artificial  eye.* 

14.— INJURIES  AND  WOUNDS  OF  THE  CORNEA. 

Foreign  bodies  are  frequently  met  with  on  the  cornea,  and  amongst 
the  most  common  are  chips  or  splinters  of  iron,  steel,  wood,  glass,  etc., 
wliich  have  become  lodged  or  impacted  on  the  sui'face,  or  more  or  less 
deeply  in  the  substance  of  the  cornea.  The  presence  of  a  foreign  body 
on  the  cornea  generally  at  once  excites  considerable  reaction.  The  eye 
becomes  flushed  and  painful,  and  this  is  accompanied  by  photophobia 
and  lachrymation.  There  is  a  well-marked  rosy  zone  around  the  cornea, 
and  on  account  of  the  ciliary  irritation  the  pupil  is  contracted.  There 
is  generally  no  difficulty  in  detecting  the  presence  of  a  foreign  body  in 
the  cornea,  more  especially  if  the  former  is  dark  (eg.,  a  chip  of  steel  or 
iron),  and  if  the  eye  is  turned  sideways  to  the  light.  But  if  any  doubt 
exists  as  to  the  presence  and  exact  situation  of  a  foreign  body,  atropine 

*  Vide  an  excellent  description  of  (liis  operation  in  tlie  Frencli  Translation  of 
Mackenzie's  Diseases  of  the  Eye,  vol.  iii,  18G7. 


INJURIES   AND  WOUNDS   OF   THE   CORNEA.  141 

should  be  applied,  and  the  eje  examined  with  the  oblique  illumination, 
and,  if  necessary,  with  the  aid  of  a  magnifying  glass.  The  advantage 
of  employing  atropine  is,  that  the  dark  background  afforded  by  the 
widely  dilated  pupil  throws  the  cornea  into  strong  relief,  and  thus  foci- 
litates  the  detection  of  a  foreign  body,  particularly  if  this  be  light 
coloured,  as,  for  instance,  a  splinter  of  glass. 

If  the  foreign  body  is  situated  superficially,  and  is  early  removed, 
no  trace  of  its  presence  may  remain.  If,  however,  it  has  escaped  detec- 
tion, or  the  patient  has  not  sought  relief,  and  the  foreign  body  is  allowed 
to  remain  in  the  cornea,  it  may  set  up  very  considerable  corneitis, 
and"  even  iritis,  accompanied,  perhaps,  with  hypopyon.  The  cornea 
around  the  foreign  body  becomes  infiltrated,  and  even  a  more  or  less 
extensive  ulcer  may  be  formed,  or  suppurative  corneitis  may  supervene, 
with  hypopyon,  iritis,  and  sloughing  of  the  cornea.  This  is  often 
observed  in  aged  and  decrcpid  individuals,  when  a  foreign  body  (e.g.,  a 
portion  of  wheat  ear,  a  splinter  of  glass)  has  become  impacted  in  the 
substance  of  the  cornea.  In  other  and  rarer  instances,  a  layer  of  lymph 
surrounds  and  encapsules  the  foreign  body,  which  remains  innocuous 
in  the  very  substance  of  the  cornea.  Sometimes  a  splinter  of  steel 
or  iron  passes  partly  through  the  cornea,  and  projects  somewhat  into 
the  anterior  chamber,  lying  half  in  the  latter,  and  half  in  the  cornea. 

There  is  generally  no  difficulty  in  removing  chips  of  steel,  iron,  or 
glass  lodged  upon  the  anterior  surface  of  the  cornea,  close  beneath  the 
epithelial  layer.  As  a  rule,  I  always  prefer  to  keep  the  eyelids  apart 
with  the  stop  speculum,  and  to  fix  the  eye  with  a  pair  of  forceps.  By 
so  doing  we  avoid  all  risk  from  any  sudden  movement  or  start  of  the 
patient,  and  can  accomplish  the  removal  of  the  foreign  body  very 
quickly  and  efiiciently.  The  application  of  the  speculum  and  forceps 
undoubtedly  causes  some  degree  of  pain,  but  this  is  raore  than  counter- 
balanced by  the  advantage  of  having  the  eye  completely  under  our 
control.  I  have  but  too  often  seen  that  after  numerous  ineffectual  and 
painful  attempts  to  remove  the  foreign  body,  recourse  had,  after  all,  to 
be  had  to  them.  The  patient  should  sit  on  a  chair  either  directly  facing 
the  light,  or  if  the  foreign  body  can  be  better  seen,  with  the  face  turned 
sideways  towards  it,  and  his  head  should  lean  back  against  the  breast 
of  the  operator,  who  should  stand  behind  him.  Having  applied  the 
speculum,  the  surgeon  steadies  the  eyeball  with  a  pair  of  forceps,  held 
in  his  left  hand,  and  endeavours  to  remove  the  foreign  body  with  the 
spud  by  passing  the  instrument  behind  it  and  thus  lifting  it  out.  If 
the  foreign  body  is  impacted  deeply  in  the  substance  of  the  cornea, 
there  arises  the  danger  that  in  our  enfleavours  to  remove  it  we  should 
push  it  further  in,  or  cause  it  to  perforate  and  fall  into  the  anterior 
chamber.  A  broad  needle  should  in  such  a  case  be  carefully  passed 
behind  the  foreign  body,  and  this  be  lifted  out.     If  it  lies  very  near  the 


142  DISEASES   OF   THE   CORNEA. 

posterior  wall  of  the  cornea,  the  needle  may  be  passed  into  the  anterior 
chamber  and  the  broad  part  of  its  blade  pressed  against  that  portion  of 
the  posterior  wall  of  the  cornea  which  is  opposite  the  foreign  body,  so 
as  to  steady  this,  and  then  it  may  be  removed  with  another  needle  or  a 
very  fine  pair  of  forceps.  A  similar  proceeding  is  to  be  adopted  if  the 
foreign  body  protrudes  partly  into  the  anterior  chamber,  for  then  an 
iridectomy  knife  or  a  broad  needle  should  be  passed  into  the  latter  and 
pushed  behind  the  foreign  body,  gently  pressing  this  back  into  the 
cornea  ;  its  anterior  end  should  be  seized  with  a  pair  of  forceps,  and  in 
this  way  it  may  be  readily  extracted.  If  a  bit  of  steel  is  situated  on 
the  surface  of  the  cornea,  it  may  also  be  removed  with  a  magnet. 
After  the  removal  of  a  foreign  body  from  the  cornea,  a  drop  or  two  of 
castor-oil  should  be  applied  to  the  eye  to  lubricate  the  parts.  After- 
wards atropine  should  be  applied,  in  order  to  allay  the  irritation.  If 
the  latter  is  considerable,  and  accompanied  by  severe  ciliary  neuralgia, 
cold  compresses,  and  leeches  are  indicated,  followed  by  warm  poppy 
fomentations.  The  use  of  the  eyes  must  be  forbidden  until  all  symptoms 
of  irritation  have  subsided. 

The  effects  which  burns,  injuries  from  quick-lime,  molten  lead,  and 
chemical  agents  may  have  upon  the  cornea  have  already  been  described 
under  the  injuries  to  the  conjunctiva  (p.  81),  and  the  same  course  of 
treatment  is  to  be  pursued  as  was  advocated  there. 

Wounds  of  the  Cornea. — The  danger  to  be  feared  from  these  varies 
according  to  their  extent,  situation,  and  nature.  It  occasionally  hap- 
pens that  a  very  superficial  cut  with  a  sharp  instrument  does  not 
perforate  the  cornea,  but  simply  penetrates  into  its  substance,  and 
forms  a  small  flap,  Avhich  may  heal  readily  by  the  first  intention,  with- 
out leaving  any  trace.  Thus  a  small,  clean  cut  or  puncture  of  the 
cornea  frequently  heals  without  leaving  any  mark  behind,  as  is  daily 
evidenced  by  operations  upon  the  cornea,  as,  for  instance,  those  for 
cataract,  either  performed  with  a  knife  or  by  the  needle.  The  chief 
danger  of  penetrating  wounds  of  the  cornea  is  that  they  may  cause 
considerable  prolapse  of  the  iris,  or  that  they  should  implicate  the  iris 
and  lens,  and  thus  set  up  severe  iritis  or  traumatic  cataract.  In  such 
cases  the  condition  not  only  of  the  cornea,  but  also  of  the  iris  and  lens, 
must  be  carefully  watched,  for  any  implication  of  these  structures  of 
course  greatly  enhances  the  danger  of  the  accident.  Bruises  of  the 
cornea  by  blunt  instruments  also  often  prove  very  dangerous,  as,  on 
account  of  the  contusion  of  the  injui^ed  part  and  its  vicinity,  severe 
inflammation,  perhaps  of  a  suppurative  character,  is  set  up,  which  may 
even  lead  to  suppuration  of  the  cornea. 

In  the  treatment  of  injuries  or  wounds  of  the  cornea  the  first  in- 
dication is  to  subdue  the  symptoms  of  irritation  and  inflammation.  If 
there  is  great  pain,  cold  compresses  should  be  sedulously  employed,  or 


INJURIES   AXD  WOUNDS   OF   THE   CORNEA.  143 

a  few  leeches  sliould  be  applied  to  the  temple,  followed  by  hot  poppy 
fomentations,  so  that  free  after- bleeding  may  be  enconi'aged.  A  strong 
solution  of  atropine  should  be  prescribed,  the  compound  belladonna 
ointm.ent  be  rubbed  over  the  forehead,  and  a  light,  though  firm  com- 
press bandage  be  applied,  in  order  that  the  parts  may  be  kept  perfectly 
at  rest.  If  the  symptoms  of  inflammation  do  not  readily  yield  to  such 
treatment,  the  eye  should  be  again  most  cai'efully  examined  in  order 
that  it  may  be  ascertained  whether  a  little  foreign  body  has  not  re- 
mained undetected  in  the  cornea,  anterior  chamber,  or  iris.  The  various 
complications,  such  as  prolapse  of  the  iris,  iritis,  traumatic  cataract, 
etc.,  must  be  treated  according  to  the  general  rules  laid  down  in  the 
sections  in  which  these  affections  are  described.  If  an  incised  wound 
is  situated  partly  in  the  cornea  and  partly  in  the  sclerotic,  it  occurs 
sometimes  that  the  portion  in  the  latter  situation  does  not  heal  readily, 
and  that  a  little  fistulous  opening  may  remain.  In  such  cases  the  treat- 
ment is  to  unite  the  wound  in  the  sclerotic  by  means  of  one  or  two 
fine  sutui'es,  according  to  its  extent.  This  will  keep  the  lips  of  the 
incision  in  contact,  plastic  lymph  will  be  efiused,  and  a  firm  union  will 
soon  be  effected.  The  thread  should  carry  a  needle  at  each  end,  so 
that  we  may  be  able  to  insert  the  suture  into  the  sclerotic  from  ivithin 
outwards,  otherwise  a  sudden  start  of  the  patient  might  cause  the  point 
of  the  needle  to  penetrate  the  eye. 

Tuviotcrs  of  the  cornea  are  very  rarely  indeed  met  with  as  originating 
in  the  tissue  of  the  cornea  itself,  and  almost  always  pass  over  on  to 
it  from  the  conjunctiva.  The  dermoid  tumour  is  of  most  frequent 
occurrence,  and  has  been  already  described  at  length  in  the  article  upon 
tumours  of  the  conjunctiva  (p.  84).  Stellwag*  describes  a  case  of 
primary  cancer  of  the  cornea,  and  this  is,  I  believe,  the  only  case  of  the 
kind  on  record. 

*  *  "  Die  Oplithalmologie  vom  uaturw.  Standp."  I,  347. 


Chapter  III. 
DISEASES    OF    THE    IPJS. 


1.— HYPEREMIA  OF  THE  IRIS. 

Hyperemia  of  the  iris  is  of  far  more  frequent  occurrence  than  is 
generally  supposed.  Nor  can  we  be  surprised  at  this  when  we  remem- 
ber the  close  connection  which  exists  between  the  iris  and  cornea  on 
the  one  hand,  and  the  iris,  ciliary  body,  and  choroid  on  the  other. 
Indeed,  we  may  regard  the  iris  as  the  anterior  termination  of  the  ciliary 
body  and  choroid,  the  whole  forming,  in  reality,  one  tissue,  the  uveal 
tract.  Hence  the  frequency  with  which  inflammation  of  the  iris 
extends  to  the  ciliary  body  and  choroid,  and  vice  versa.  In  a  hyper- 
cemic  condition  of  the  iris,  we  find  that  there  is  more  or  less  marked 
subconjunctival  injection;  that  the  pupil  is  somewhat  contracted  and 
sluggish,  not  re-acting  freely  on  the  application  of  atropine ;  and  that 
the  iiis  is  discoloured,  which  is  due  to  the  increased  vascularity  im- 
parting a  reddish  tint  to  the  natural  colour  of  the  iris.  Thus  a  blue 
iris  will  become  somewhat  green,  and  a  brown  iris  assume  a  slight 
admixture  of  red. 

All  causes  which  produce  congestion  of  the  deeper  tunics  of  the 
eye  may  excite  hyperaemia  of  the  iris.  Of  these  the  most  frequent  are 
over-exertion  of  the  eyes  in  reading,  engraving,  etc.,  and  inflammatory 
affections  of  the  choroid,  ciliary  body,  and  cornea.  But  this  condition 
may  even  be  produced  in  acute  granular  ophthalmia,  if  this  is  injudi- 
ciously treated  by  caustics  and  strong  astringent  collyria. 

The  treatment  must  be  chiefly  directed  towards  a  removal  of  the 
cause,  and  an  alleviation  of  the  ii-ritation ;  hence  strict  and  prolonged 
rest  of  the  eyes  should  be  enforced,  and  they  should  also  be  guarded 
against  exposure  to  strong  light,  cold,  etc.  Atropine  should  be  applied 
to  diminish  the  irritability  of  the  eye. 

2.— INFLAMMATION  OF  THE  IRIS. 

In  iritis  there  are  superadded  to  the  symptoms  of  hyperaemia  of  the 
iris  those  of  an  cifasitjn  of  plastic  lymph  at  the  edge  of  the  pupil,  or 
on  the  surface  and  into  the  stroma  of  the  iris. 


INFLAMMATION   OF   THE   IRIS.  145 

Formerly  tlie  inflammations  of  the  iris  were  classified  according  to 
the  dyscrasiae  of  which  they  were  supposed  to  be  pathognomonic,  and 
a  formidable  array  of  different  forms  of  iritis  was  in  this  way  esta- 
blished. By  chiefly  basing  our  classification  on  pathological  anatomy, 
we  can,  however,  greatly  simplify  the  subject  and  so  embrace  all  shades 
of  iritis  within  the  following  four  groups.  1.  Simple  idiopathic  ileitis. 
2.  Serous  iritis  (Descemetitis,  etc).  3.  Parenchymatous  iritis. 
4.   SyphUitic  iritis. 

In  order  to  avoid  unnecessary  repetition,  I  shall  first  describe  the 
various  symptoms  which  more  or  less  accompany  all  inflammations  of 
the  iris,  and  then  call  attention  to  those  which  characterise  the  special 
forms. 

Amongst  the  earliest  symptoms  of  iritis  are  conjunctival,  and 
especially  subconjunctival  injection,  ciliary  neuralgia,  contraction  and 
sluggishness  of  the  pupil,  and  a  discoloured,  dull,  lack-lustre  appearance 
of  the  iris. 

There  is  generally  some  injection  of  the  conjunctiva,  which  may  be 
chiefly  confined  to  the  palpebral  portion,  or  extend  also  to  the  ocular 
conjunctiva  in  the  vicinity  of  the  cornea.  But  a  far  more  constant 
symptom  is  the  subconjunctival  vascularity,  giving  rise  to  a  more  or 
less  bi'oad  rosy  zone  of  parallel  vessels,  closely  ranged  round  the  cornea. 
This  zone  is  generally  of  a  bright  rose  colour,  and  consists  chiefly  of  small 
arterial  twigs.  It  may,  however,  assume  a  somewhat  blue  or  brownish 
tint.  The  latter  was  formerly  erroneously  supposed  to  be  symptomatic 
of  syphilitic  iritis.  Although  marked  subconjunctival  injection  is 
present  in  the  great  majority  of  cases  of  iritis,  we  occasionally  meet 
with  severe  cases  in  which  it  is  not  very  conspicuous,  as  in  typhus 
fever,  pyaemia,  etc.  (Stellwag).  There  is  also  more  or  less  chemosis, 
and  this  may  be  so  considerable  that  the  conjunctiva  is  raised  like  a  red 
or  bluish-red  mound  round  the  cornea.  The  eyeHds  are  often  also 
swollen  and  puffy.  In  the  milder  cases  they  may  retain  their  normal 
appearance,  but  if  the  attack  is  severe,  the  upper  lid  generally  becomes 
red,  glistening,  and  very  oedematous  and  swollen.  This  is  more 
especially  the  case  in  suppui\'\tive  iritis  or  irido-cyclitis. 

The  intensity  of  the  pain  is  very  variable,  for  although  it  is 
generally  severe,  and  often  extremely  so,  it  may  in  some  cases  be 
nearly  entirely  absent.  The  patient  may  at  first  only  experience  a 
feeling  of  itching  and  burning  in  the  eye,  but  soon  the  pain  becomes 
more  severe,  and  assumes  a  sharp,  cutting,  lancinating  character.  It 
may  be  chiefly  situated  deeply  in  the  eyeball,  or  extend  to  the  forehead, 
temple,  and  corresponding  side  of  the  nose  (ciliary  neuralgia).  Some- 
times there  is  very  intense  neuralgia  of  the  branches  of  the  fifth  nerve, 
extending  over  the  corresponding  side  of  the  face  and  head,  even  as  far 
as  the  occiput.    The  pain  always  increases  in  intensity  towards  evening, 

L 


146  DISEASES  OF   THE  IRIS. 

remaining  very  severe  during  the  night,  and  diminishing  towards 
morning.  Although  the  patient  may  experience  very  acute  'pain  in 
iritis,  it  is  important  to  remember  that  the  eye  is  not  painful  to  the 
touch  in  a  case  of  simple  uncomplicated  iritis.  If  sharp  pain  is  caused 
when  the  ciliary  region  is  pressed  by  the  finger,  it  is  indicative  of  the 
co-existence  of  inflammation  of  the  ciliary  body  (cyclitis).  Very  fre- 
quently this  tenderness  is  partial,  and  confined  to  the  upper  portion  of 
the  ciliary  region. 

The  severity  of  the  pain  may  give  rise  to  some  constitutional  dis- 
turbance, and  the  exacerbations  be  accompanied  by  feverishness,  a 
loaded  tongue,  impairment  of  appetite,  and  a  tendency  to  retching  and 
vomiting,  which  not  unfrequently  causes  the  disease  to  be  mistaken  for 
a  severe  bihous  attack. 

Although  considerable  photophobia  and  laclirymation  may  accom- 
pany iritis,  they  are  seldom  so  severe  and  marked  as  in  certain  forms  of 
comeitis. 

We  now  come  to  the  symptoms  presented  by  the  iris  itself.  Amongst 
the  earliest  are  discoloration  and  dulness  of  the  iris,  and  contraction 
of  the  pupil.  The  discoloration  of  the  iris  is  partly  due  to  hyperaemia 
and  partly  to  an  effusion  into  its  structure.  In  order  to  estimate  rightly 
the  changes  in  colour,  we  must  always  compare  the  afiected  with  the 
other  eye  (if  this  be  sound),  otherwise  an  error  may  easily  occur.  We 
must  also  be  upon  our  guard  not  to  mistake  the  dullness  and  change  in 
the  tint  of  the  iris,  which  may  be  produced  by  cloudiness  of  the  cornea 
and  of  the  aqueous  humoui*,  as  being  resident  in  the  iris  itself.  Besides 
the  discoloration,  the  iris  presents  a  peculiar  dull,  lack-lustre  ap- 
pearance, its  surface  having  lost  its  natural  bright,  glistening  aspect, 
and  appearing  hazy  and  dull,  as  if  covered  by  a  fine  veil.  Its  fibrillee  are 
also  not  sharply  defined,  but  indistinct  and  blurred.  This  depends  in  a 
great  measure  upon  the  hypertrophy  of  the  connective  tissue  elements 
of  the  ii'is,  and  upon  the  efiusion  of  lymph  into  the  stroraa  and  upon 
the  surface  of  the  iris. 

The  pupil  is  sluggish  and  more  or  less  contracted.  This  generally 
occurs  in  all  but  the  very  slightest  cases  of  iritis,  or  in  those  in  which 
there  is  a  tendency  to  increase  in  the  intra- ocular  tension.  This  immo- 
bility of  the  pupil  is  partly  caused  by  the  hyperemia  of  the  vessels,  but 
chiefly  by  the  serous  or  plastic  effusion  which  has  taken  place  into  the 
stroma  of  the  iris,  and  impedes  the  action  of  the  circular  fibres  of  the  iris. 
If  the  inflammation  is  but  partial,  the  immobility  of  the  pupil  may  be 
the  sarae.  In  testing  the  mobility  of  the  pupil,  the  patient  should  be 
placed  so  that  the  light  falls  sideways  upon  the  eye.  The  other  must 
be  firmly  closed  with  our  hand,  or  by  a  handkerchief.  The  afiected  eye 
is  to  be  shaded  with  the  palm  of  our  hand,  which  is  then  to  be  rapidly 
removed  so  as  to  admit  the  light,  and  the  behaviour  of  the  pupil  accu- 


ixflam:\iation  of  the  iris.  147 

rately  watclied,  so  tliat  its  size,  mobility,  and  tlie  extent  of  its  contrac- 
tions may  be  ascertained.  It  must  be  remembered  that  contraction  and 
impaii'ed  mobility  of  the  pupil  may  exist  without  any  iritis ;  for  it  may 
be  seen  in  corneitis,  hyperasniia  of  the  iris,  or  if  a  foreign  body  is 
lodged  on  the  cornea,  and  is  in  these  cases  due  to  irritation  of  the 
ciliary  nerves. 

The  edge  of  the  pupil  generally  soon  loses  its  circular  form  and 
becomes  somewhat  irregular,  and  we  may  notice  along  it  small 
exudations  or  beads  of  plastic  lymph,  which  tie  it  down  to  the  anterior 
capsule.  These  may,  however,  be  so  minute  as  to  escape  detection 
until  the  pupil  is  examined  with  the  oblique  illumination,  or  atropine  is 
applied.  The  individual  exudations  often  increase  in  size  and  coalesce, 
and,  more  lymph  being  effused,  the  whole  circumference  of  the  pupil 
may  become  fringed  with  them  and  be  tied  down  to  the  capsule  of  the 
lens,  the  centre  of  the  pupil  perhaps  remaining  clear  and  thus  still  per- 
mitting of  good  vision.  This  condition  is  termed  ^^  circular^'  or 
"  annular"  synechia,  or  ^^  exclusion  of  the  piq^il.'^  We  must  distinguish 
this  from  the  condition  in  which  the  eflPasion  invades  the  area  of  the 
,  pupil,  so  that  a  m.ore  or  less  considerable  portion  of  it  is  covered  by  a 
film  of  lymph,  or  even  the  whole  of  it  occluded  by  a  thick  nodule  of 
exudation,  the  sight  being  of  course  proportionately  deteriorated ;  this 
is  called  occlusion  of  the  pupil.  The  exudation  of  lymph  between  the 
iris  and  the  capsule  of  the  lens  is  not  always  limited  to  the  edge  of  the 
pupil,  but  may  extend  further  back  along  the  posterior  surface  of  the 
iris,  and  thus  produce  broad  and  very  firm  adhesions.  We  shall  see 
hereafter,  that  this  fact  is  of  great  importance  in  the  performance  of 
iridectomy  for  chronic  iritis  or  ii-ido-choroiditis.  The  partial  adhesions 
between  the  pupil  and  capsule  vary  greatly  in  thickness,  extent,  and 
number,  and  become  very  apparent  when  atropine  is  applied,  as  they 
then  give  rise  to  various  irregularities  in.  the  shape  of  the  pupil. 

The  sui'face  of  the  iris  may  become  covered  with  a  film  of  exuda- 
tion, or  the  lymph  may  mix  with  the  aqueous  humour  and  render  this 
turbid  and  clouded  ;  or  it  may  be  precipitated  against  the  posterior  wall 
of  the  cornea  in  the  form  of  small  whitish  opacities  ;  or  again,  it  may 
sink  to  the  bottom  of  the  anterior  chamber,  where  it  collects  in  the 
form  of  an  hypopyon.  The  amount  of  this  yellowish  deposit  varies  ;  it 
may  be  so  shght  as  easily  to  escape  detection,  appearing  simply  Hke  a 
small  yellow  fringe  along  the  lower  edge  of  the  anterior  chamber  ;  or  it 
may  attain  such  a  size  that  it  fills  half  or  even  more  of  the   anterior 

chamber. 

In  simple  iritis  the  cornea  is  generally  quite  transparent,  or  shows  but 
the  faintest  amount  of  cloudiness.  Small  portions  (jf  lymph  may,  how- 
ever, be  deposited  from  the  aqueous  humour  upon  the  posterior  wall  of 
the  cornea,  giving  rise  to  a  punctated  appearance.  This  occui-s  especially 

L  2 


148  DISEASES   OF   THE  IRIS. 

in  the  serous  form  of  iritis.     But  the  cornea  may,  also,  become  impli- 
cated in  the  inflammatory  process. 

Vision  is  often  considerably  impaired.  This  may  be  partly  due  to 
the  cloudiness  of  the  aqueous  humour  and  of  the  area  of  the  pupil.  If 
the  sight  is  much  aflTected  and  the  pupil  not  occluded,  we  must  suspect 
the  co-existence  of  cyclitis,  which  is  often  accompanied  by  difiuse 
opacity  of  the  vitreous  humour.  The  power  of  accommodation  is  then, 
naoreover,  also  affected.  It  is,  therefore,  very  necessary  accurately  to 
test  the  degree  of  vision  at  the  commencement  of  an  iritis,  in  order 
that  we  may  at  once  detect  any  marked  deterioration,  and  ascertain  to 
what  cause  this  is  due.  The  tension  of  the  eyeball  is  normal  in  a  case 
of  common  iritis,  and  the  field  of  vision,  although  it  may  be  somewhat 
contracted  on  account  of  the  smallness  of  the  pupil,  or  the  presence  of 
synechia,  does  not  show  the  contraction  peculiar  to  a  glaucomatous 
condition  of  the  eye. 

We  must  now  consider  the  symptoms  by  which  the  special  forms 
of  iritis  are  characterised. 

1.  The  Simple  Idiopathic  Iritis  is  sometimes  very  slight  in  degree, 
and  accompanied  by  only  a  very  moderate  amount  of  subconjunctival 
injection,  photophobia,  pain,  or  discolouration  of  the  iris ;  indeed,  its 
existence  may  remain  quite  unsuspected  until  atropine  is  applied,  when 
the  pupil  is  found  to  be  irregular,  and  shows  here  and  there  a  slender 
adhesion  to  the  capsule.  This  mild  form  of  iritis  is  often  met  with 
after  operations  upon  the  eye  (e.gr.,  cataract  operations),  or  after 
injuries.  The  affection  may,  however,  be  more  severe,  and  there  is 
much  pain,  swelling  of  the  lids,  injection  of  the  conjunctiva  and  sub- 
conjunctival tissue,  chemosis,  photophobia,  and  lachrymation.  The 
iris  is  discoloui^ed,  the  pupil  contracted  and  inactive,  having  deposits  of 
lymph  at  its  edge  and  perhaps  also  in  its  area.  A  film  of  exudation 
covers  the  surface  of  the  iris,  rendering  it  dull  and  hazy,  the  aqueous 
humour  is  somewhat  tui'bid,  and  the  posterior  surface  of  the  cornea 
perhaps  mottled  with  small  deposits  of  lymph. 

2.  Serous  Iritis  (syn.  Descemetitis,  aquo- capsulitis,  keratitis  punctata, 
etc.)  is  chiefly  distinguished  by  the  absence  of  plastic  exudation,  and 
by  the  great  tendency  to  hypersecretion  of  the  aqueous  humotir.  The 
symptoms  of  acute  iritis  are  generally  not  very  pronounced.  The  aqueous 
humour  is  secreted  in  greater  quantity,  and  is  somewhat  clouded  and 
turbid,  and  on  closer  observation  we  can  often  notice  small  particles  of 
lymph  floating  about  in  it,  before  becoming  deposited  on  the  posterior 
surface  of  the  cornea,  or  at  the  bottom  of  the  anterior  chamber.  The 
latter  is  often  markedly  deepened,  and  the  cornea  appears  somewhat 
bulged  forward.  The  cloudiness  of  the  aqueous  humour  often  varies 
considerably  and  rapidly  within  the  course  of  a  few  hours.  The  cornea 
may  at  first  appear  abnormally  brilliant,  but  it  soon  loses  its  lustre  and 


INFLAMMATION   OP  THE   IRIS.  149 

becomes  slightly  clouded,  and  small  punctated  opacities  make  their  ap- 
pearance upon  its  posterior  surface.  These  are  sometimes  situated  op- 
posite the  pupil  and  are  grouped  in  a  small  circle  ;  but  they  are  generally 
arranged  in  the  form  of  a  pyramid,  the  base  of  which  is  turned  towards 
the  periphery  of  the  cornea,  and  its  apex  towards  the  centre.  The 
smaller  opacities  being  situated  at  the  apex  and  the  larger  and  coarser 
ones  at  the  base.  This  proves  that  the  opacities  are  composed  of  small 
masses  of  lymph,  deposited  from  the  aqueous  humour  upon  the  posterior 
wall  of  the  cornea,  and  that  they  arrange  themselves  according  to  their 
size  and  weight,  the  lai'ger  and  heavier  ones  gravitating  downwards. 
The  ti'uth  of  this  assertion  has  moreover  been  proved  experimentally  by 
Arlt.  He  placed  the  head  of  the  patient  in  different  directions,  some- 
times keeping  it  for  a  length  of  time  turned  to  the  right  side,  sometimes 
to  the  left,  and  he  found  that  the  base  of  the  pyramid  always  corre- 
sponded to  the  side  of  the  eye  which  had  been  maintained  in  the  lowest 
position.  But  some  of  the  opacities  met  with  at  the  posterior  portion 
of  the  cornea  are  not  due  to  these  deposits  from  the  aqueous  humour, 
but  are  caused  by  inflammatory  changes  in  the  epithelial  layer,  or  even 
in  the  posterior  portion  of  the  cornea  proper. 

The  iris  is  but  slightly  discoloured,  and  the  pupil,  instead  of  being 
contracted,  as  is  generally  the  case  in  iritis,  is  somewhat  dilated,  often 
markedly  so.  This  is  due  to  an  increase  in  the  intra-ocular  tension, 
which  is  often  present  in  this  disease,  and  the  manifestation  of  which 
must  be  watched  with  the  gTeatest  care,  for  this  serous  form  of  inflam- 
mation shows  a  great  tendency  to  extend  to  the  ciliary  body  and  choroid, 
which  is  accompanied  by  an  hypersecretion  of  the  vitreous  humour, 
marked  increase  in  the  intra-ocular  tension,  and  a  glaucomatous  con- 
dition of  the  eye.  The  degree  of  eye  tension,  the  state  of  the  sight  and 
of  the  field  of  vision  must,  therefore,  be  frequently  and  carefully 
examined  during  the  course  of  the  disease,  in  order  that  the  earliest 
symptoms  of  a  glaucomatous  complication  may  be  detected  and  at  once 
arrested.  Adhesions  between  the  edge  of  the  pupil  and  the  capsule  are 
not  of  frequent  occurrence  in  this  f«rm. 

Serous  iritis  occasionally  accompanies  deep-seated  inflammations  of 
the  eye,  more  especially  clu-onic  ii-ido- choroiditis,  and  choroido-retinitis. 
Moreover,  sympathetic  ophthalmia  sometimes  appears  in  the  form  of 
serous  iritis.  It  has  also  been  supposed  to  be  due  to  constitutional  or 
hereditary  syphihs. 

3.  Parenchymatous  or  suppurative  iritis. — In  this  affection  the  in- 
flammation attacks  the  tissue  of  the  iris,  and  its  fibrilla3  become  much 
swollen  and  thickened.  The  plastic  exudation  is  poured  out  into  the 
parenchyma  of  the  iris,  along  the  edge  and  into  the  area  of  the  papil, 
and  also  on  the  posterior  surface  of  the  iris,  giving  rise  to  thick  broad 
adhesions  between  it  and  the  capsule  of  the  lens.     On  account  of  the 


150  DISEASES  OP   THE  IRIS. 

exudation  into  the  stroma  of  tlie  iris,  and  the  swollen  and  thickened 
condition  of  its  fibrillse,  the  circulation  is  generally  considerably  impeded, 
and  large  tortuous  veins  raake  their  appearance  on  its  sui'face.  Along 
the  edge  of  the  contracted  pupil  are  noticed  a  number  of  thick  firm 
nodules  of  exudation,  of  a  creamy  or  reddish-brown  colour,  tying  down 
the  edge  of  the  pupil  to  the  capsule ;  or  they  may  even  extend 
around  the  whole  edge  of  the  pupil,  and  thus  give  rise  to  a  circular 
synechia  (exclusion  of  the  pupil) .  The  efiusion  generally  also  invades 
the  area  of  the  pupil,  indeed  the  latter  may  be  completely  blocked  up 
by  a  thick  yellow  nodule  of  purulent  exudation.  The  surface  of  the 
iris  appears  indistinct  and  hazy,  its  fibrill^  are  swollen,  and  its  anterior 
surface  is  covered  by  a  layer  of  exudation  which  varies  considerably  in 
appearance.  In  some  cases  it  looks  simply  like  a  thin  grey  veil  cover- 
ing different  portions  or  even  the  whole  of  the  iris,  in  others  it  assumes 
a  thick,  creamy,  purulent  appearance,  with  small  extravasations  of  blood 
scattered  about  here  and  there.  Little  yellow  nodules  (which  are  not 
to  be  confounded  with  the  syphilitic  tubercles)  may  also  appear  strewn 
about  on  the  surface  of  the  iris.  On  account  of  the  detachment  of  some 
of  these  nodules,  and  the  effusion  of  lymph  and  purulent  exudation  into 
the  aqueous  humoiu*,  the  latter  becomes  turbid  and  discoloured,  Flakes 
of  pui^ulent  lymph  and  globules  of  pus  are  seen  floating  about  in  it,  and 
sinking  down,  give  rise  to  an  hypopyon,  which  may  be  so  small  as  to 
appear  only  like  a  narrow  yellow  belt  along  the  lower  edge  of  the 
anterior  chamber,  or  may  be  so  considerable  as  to  occupy  one-half  or 
more  of  the  anterior  chamber,  reaching  perhaps  above  the  upper  edge 
of  the  pupil.  Tliis  parenchymatous  or  suppurative  iritis,  may  be  ac- 
companied by  a  similar  form  of  inflammation  of  the  ciliary  body  and 
choroid. 

4.  SypMlltlc  iritis  generally  assumes  the  parenchymatous  form.  It 
is,  however,  especially  characterised  by  the  formation  of  peculiar 
tuberculous  nodules  (gummy  tubercles,  Virchow).  These  are  scattered 
about  singly  over  a  certain  portion,  or  even  the  whole,  of  the  surface  of 
the  ii'is,  in  the  forra  of  yellowish-^ed  condylomatous  nodules.  They 
appear  at  first  deeply  imbedded  in  the  parenchyma  of  the  iris  (origi- 
nating in  the  deeper  portion  of  its  connective  tissue),  and  as  they  increase 
in  size,  they  push  aside  the  fibrillse  of  the  iris,  and  protrude  between 
them  into  the  anterior  chamber.  They  may  attain  a  very  considerable 
size,  their  apex  even  touching  the  posterior  wall  of  the  cornea.  They 
(according  to  Colbert)  exactly  resemble  in  structure  the  gummy  tuber- 
cles (gummata)  of  Vii'chow.  On  account  of  the  presence  of  pigment  cells, 
and  the  great  vascularity,  the  nodules  frequently  assume  a  dark  reddish- 
brown  sarcomatous  appearance.  They  often  undergo  fatty  and  purulent 
degeneration,  breaking  down  into  a  yellow  grumous,  purulent  mass, 
which  becomes  mixed  with  the  aqueous  humour.     They  may,  however, 


INFLAMMATION   OF   THE   IRIS.  151 

undergo  rapid  absorption.  These  tubercles,  or  condylomata  as  tliey  are 
sometimes  called,  frequently  remain  confined  to  one  portion  of  the  iris, 
in  which  the  inflammatory  changes  are  moreover  also  more  pronounced, 
so  that  the  disease  assumes  a  somewhat  partial  character,  which  is  pecu- 
liar to  the  syphilitic  form.  "We  find,  in  such  cases,  that  although  the 
whole  cornea  may  be  surrounded  by  a  pink  zone  of  vessels,  that  this  is 
most  pronounced  at  one  point,  and  that  the  corresponding  segment  of 
iris  is  the  most  thickened  and  swollen,  and  that  the  condylomata  are 
chiefly  or  entirely  confined  to  this  portion. 

It  must  be  distinctly  remembered  that,  although  the  name  of 
syphilitic  iritis  is  given  to  the  form  of  inflammation  above  described, 
the  iritis  which  may  occur  in  the  course  of,  and  be  entirely  due  to, 
syphilis,  does  not  necessarily  always  assume  this  type.  For  it  may 
appear  as  a  simple  idiopathic  iritis,  or  in  a  more  or  less  severe  paren- 
chymatous form,  so  that  the  absence  of  the  peculiar  gummy  tubercles 
does  not  exclude  the  presence  of  syphilis  in  the  system,  or  its  being  the 
cause  of  the  u-itis.  But  on  the  other  hand,  the  existence  of  these  tuber- 
cles may,  in  the  vast  majority  of  cases,  be  taken  as  a  certain  indication 
of  the  syphilitic  natui*e  of  the  inflammation.  I  can  only  remember 
having  seen  one  case  (a  patient  of  Mr.  Critchett's)  in  which  there 
were  well  marked  condylomata  without  the  slightest  evidence  of 
syphihs.  Some  authors  have  stated  that  in  syphilitic  iritis  the  circum- 
corneal  zone  of  injection  is  of  a  brownish  tint,  and  that  the  pupil  is 
displaced  upwards  and  inwards.  This  is,  however,  not  the  case,  for  both 
these  appearances  may  be  met  with  apart  from  syphilis. 

Amongst  the  cmises  of  iritis,  a  very  frequent  one  is  exposure  to 
sudden  changes  of  temperature,  cold  draughts  of  air,  rain,  wind,  etc. 
The  disease  is,  in  such  cases,  often  termed  rheumatic  iritis.  It  may 
also  accompany  rheumatism  in  other  parts  of  the  body,  being  evidently 
produced  by  the  same  cause.  It  is  erroneous,  however,  to  speak  of  rheu- 
matic ii'itis  as  a  special  form  of  the  disease,  for  it  has,  in  truth,  no 
characteristic  symptoms  ;  it  generally  assumes  the  form  of  simple  u'itis, 
and  may  vary  greatly  in  severity,  but  is  not,  as  a  rule,  accompanied  by 
extensive  exudative  changes  in  the  parenchyma  of  the  ii'is,  or  by  con- 
siderable hypopyon.  The  pain  is  frequently  extremely  severe,  and 
may  extend  over  the  corresponding  side  of  the  head  and  face.  The 
disease  often  runs  a  chronic  and  very  protracted  course,  and  relapses 
may  take  place  on  a  recurrence  of  the  rheumatic  attack. 

Iritis  is  also  often  of  traumatic  origin,  being  caused  by  mechanical  or 
chemical  injuries,  which  either  afiect  the  iris  directly  or  secondarily. 
Thus,  foreign  bodies  may  remain  lodged  for  some  time  in  the  conjunc- 
tiva, cornea,  anterior  chamber,  or  in  the  deeper  tunics  of  the  eye,  and 
then  set  up  iritis.  Clean  incised  wounds  of  the  iris  are  not  prone  to 
give  rise  to  it,  as  is  proved  by  the  operation  of  iridectomy,  nor  does 


152  DISEASES   OF   THE   IRIS. 

strangulation  or  compression  generally  do  so,  as  is  evidenced  by  iridodesis. 
Wounds  whicli  bruise  and  lacerate  the  iris  are  the  most  apt  to  set  up 
iritis.  Injury  of  the  lens,  followed  by  traumatic  cataract,  very  often 
produces  it,  more  especially  if  the  iris  has  been  implicated  in  the 
injury,  or  the  lens  swells  up  very  considerably  and  presses  upon  the  iris. 
It  also  often  supervenes  secondarily  upon  other  inflammations  of  the  eye. 
Thus  corneitis,  especially  the  diffuse  and  suppurative  forms,  and  deep 
or  perforating  ulcers  of  the  cornea,  are  frequently  accompanied  by  iritis ; 
this  is  still  more  the  case  in  inflammations  of  the  choroid  and  ciliary 
body. 

Sijpliilis  is  a  very  frequent  cause.  When  primary  iritis  occurs  in 
infants  or  young  children,  it  is  almost  always  due  to  syphilis,  and  in 
such  cases  we  generally  meet  with  other  symptoms  pathognomonic  of 
the  syphihtic  taint,  such  as  condylomata  about  the  anus,  specific  erup- 
tions, etc.  In  adults  it  but  seldom  occurs  together  with  the  primary 
symptoms,  but  generally  during  the  secondary  or  tertiary  stage,  being 
often  the  precursor  of  these  symptoms,  when  the  primary  have  dis- 
appeared. The  iritis  frequently  occurs  simultaneously  with  the  syphilitic 
eruptions  of  the  skin. 

Some  authors  have  asserted  that  gonori'hoea  is  sometimes  the  cause 
of  iritis.  Thus,  Mackenzie*  describes  a  special  form,  under  the  name  of 
"  gonorrhoeal  ii-itis."  Mr.  Wordsworthf  has  also  narrated  three  cases 
in  which  iritis  occurred  together  with  gonorrhoea.  It  must,  however,  be 
stated  that  all  three  were  complicated  with  rheumatism.  I  have  myself 
never  met  with  a  case  of  iritis  associated  with  gonorrhoea  alone ;  but 
have  only  observed  it  in  cases  in  which  the  gonorrhoea  co-existed 
with  syphilis  or  with  rheumatism,  either  of  which  diseases,  as  I  have 
already  stated,  is  a  frequent  cause  of  iritis.  Nor  does  the  so-called 
"  gonorrhoeal  iritis"  present  any  special  or  pathognonaonic  features. 

Sympathetic  inflammation  of  the  iris  is  apt  to  occur  after  injuries  to 
ihe  eye,  or  the  lodgment  of  a  foreign  body  witliin  it,  etc.  The  sym- 
pathetic ii'itis  may  assume  the  serous  character,  but  generally  appears 
in  the  form  of  suppurative  u'ido-choroiditis.  (Vide  article  on  "  Sym- 
pathetic Ophthalmia.") 

Chronic  iritis  is  especially  distinguished  by  the  fact  that  the  inflam- 
matory symptoms  are  generally  but  slightly  marked,  or  are  almost  so 
entirely  absent  that  the  patient  is  not  aware  that  there  is  anything  the 
m.atter  with  his  eye,  except  a  slight  weakness  or  "cold"  in  it,  as  he 
frequently  expresses  it.  The  ocular  conjunctiva  and  subconjunctival 
tissue  are  but  slightly  injected ;  there  is  only  a  faint  pink  blush 
around  the  cornea ;  there  is  but  little  photophobia,  lachrymation,  or 
ciliary  neuralgia.     The  pupil    is  somewhat  contracted    and  sluggish, 

*  "  Mackenzie  on  Diseases  of  the  Eye,"  552. 
t  "  R.  L.  O.  n.  Rep.,"  iii,  301. 


INFLAMMATION   OF   THE   IRIS.  153 

and,  at  certain  points,  perhaps  immoveable.  On  examining  it  witli  the 
obliqne  illirmination,  we  may  frequently  notice  small  adhesions  between 
the  edge  and  the  capsule,  which,  as  well  as  the  irregulai-ity  of  the 
pupil,  become  very  evident  upon  the  application  of  atropine.  The 
colour  of  the  iris  I)ecomes  gradually  more  changed,  and  this  alteration 
in  its  tint  is  permanent,  whereas  in  acute  iritis  it  passes  off  again  with 
the  subsidence  of  the  disease,  without,  jierhaps,  eventually  leaving  any 
trace  behind.  The  normal  brightness  and  lustre  of  the  ii'is  become 
faded  and  dulled,  its  fibrillce  indistinct  and  obliterated,  and  in  the  later 
stages  of  the  disease  it  presents  a  yellowish-grey,  dirty-brown,  or  slate- 
coloured  appearance,  its  tissue  being  thinned  and  atrophied,  and 
traversed,  perhaps,  by  enlarged  and  somewhat  tortuous  blood-vessels. 
The  presence  of  such  dilated  vessels  always  indicates  a  state  of  conges- 
tion and  stasis  of  the  circulation  in  the  iris  and  ciliary  body.  At  this 
advanced  stage  the  u'itis  is  generally,  however,  no  longer  simple  in 
character,  but  has  become  complicated  with  inflammation  of  the  ciliary 
body  and  choroid.     (Vide  the  article  on  "  Irido-choroiditis.") 

Chi-onic  iritis  may  supervene  upon  a  more  acute  form  of  iritis,  or 
the  disease  may  manifest  this  chronic  and  insidious  character  from  the 
very  outset.  It  also  frequently  accompanies  inflammations  of  the  cornea, 
more  especially  the  difiuse  corneitis.  Relapses  are  very  apt  to  occur  in 
chronic  iritis ;  these  recurrent  inflammatory  exacerbations  being  often 
produced  by  very  slight  causes,  such  as  undue  use  of  the  eyes,  particu- 
larly by  artificial  light,  exposure  to  cold,  wet,  etc.  This  tendency  to 
recm'rence  is  especially  marked  in  those  cases  in  which  numerous  or 
extensive  posterior  synechite  exist.  For  theii'  presence  is  a  constant 
source  of  irritation  and  teasing,  as  they  prove  a  check  to  the  free, 
spontaneous  movements  of  the  pupil,  and  in  such  cases  a  slight  cause 
will  suffice  to  rekindle  the  inflammation.  Dm'ing  the  recurrence  of  the 
inflammation,  fresh  lymph  will  be  effused,  and  the  posterior  synechige 
will  increase  still  fiu^ther  in  number  and  firmness,  until  finally,  after 
perhaps  frequent  relapses,  the  whole  circumference  of  the  pupil  is 
fii-mly  tied  down  to  the  capsule,  and  the  communication  between  the 
anterior  and  posterior  chamber  is  completely  interrupted.  It  will  be 
seen  hereafter  that  such  an  exclusion  of  the  pupil  (circular  synechia) 
is  one  of  the  most  frequent  causes  of  irido-choroiditis. 

The  prognosis  of  iritis  will  depend  very  much  upon  the  severity  and  the 
cause  of  the  inflammation.  If  the  disease  be  seen  at  a  very  early  stage, 
before  any  adhesions  have  been  formed  between  the  edge  of  the  pupil 
and  the  capsule  of  the  lens,  or  whilst  these  are  yet  so  sKght  and  brittle, 
as  to  be  readily  torn  through  by  the  energetic  use  of  atropine,  the 
prognosis  is  in  every  way  very  much  more  favourable  than  if  numerous 
firm  posterior  synechitu  have  already  been  established,  and  resist  the 
action  of  atropine.     Parenchymatous  and   sypliilitic  iritis,  which  are 


154  DISEASES  OF  THE  IRIS. 

generally  accompanied  by  very  considerable  exudations  of  lympli  at 
the  edge  of  the  pupil,  on  the  surface  and  into  the  structure  of  the  iris, 
and  into  the  anterior  chamber,  afford  a  less  favourable  prognosis  than 
the  simple  or  serous  iritis.  The  tendency  to  implication  of  the  cornea, 
or  the  deeper  tunics  of  the  eyeball  must  also  be  borne  in  mind.  In 
traumatic  ii'itis,  the  nature  and  extent  of  the  injury,  the  presence  of 
traumatic  cataract,  or  the  co- existence  of  inflammation  of  the  ciliary 
body  or  choroid  must  all  be  taken  into  consideration  in  framing  the 
prognosis. 

Treatment. — The  patient  should  be  carefully  guarded  against  the 
injurious  influences  of  bright  light,  and  sudden  changes  of  temperature, 
as  well  as  cold  and  wet.  Perfect  rest  of  both  eyes  must  also  be  eujoined, 
and  if  the  patient  has  to  leave  the  house,  a  bandage  should  be  placed 
over  the  afiected  eye,  and  a  shade  over  the  other,  or  goggles  should 
be  worn.  But  if  the  disease  is  very  severe,  strict  orders  must  be  given 
that  the  patient  is  to  keep  in  a  darkened  room.  We  are,  however,  very 
frequently  obliged  to  treat  even  severe  cases  of  iritis  as  out-patients, 
and  may  even  in  such  instances  frequently  succeed  in  afiecting  an 
excellent  cure.  This  mode  of  treatment  should  however  only  be 
adopted  fi'om  necessity,  and  not  from  choice,  and  strict  injunctions 
should  be  given  to  the  patients  to  guard  their  eyes  as  much  as  possible 
against  all  noxious  infltiences  during  the  intervals  of  their  visits. 

The  point  of  the  very  greatest  importance  in  the  treatment  of  iritis 
is  to  obtain  a  wide  dilatation  of  the  pupil  as  soon  as  possible,  and  hence 
a  strong  solution  of  atropine  should  be  at  once  energetically  applied  to 
.the  eye.  The  beneficial  effect  of  atropine  is  three- fold : — 1.  Wide  dila- 
tation of  the  pupil  is  produced,  and  the  iris  is,  therefore,  removed  from 
the  contact  with  the  anterior  capsule  of  the  lens,  so  that  no  adhesions 
can  be  formed  between  them  at  the  edge  of  the  pupil,  or  on  the  posterior 
surface  of  the  iris.  Thus  one  of  the  chief  dangers  of  iritis,  the  forma- 
tion of  extensive  posterior  synechiEe,  is  prevented,  and  the  numerous  evil 
consequences  or  dangerous  complications  to  which  they  may  give  rise, 
are  obviated.  2.  Rest  will  be  afibrded  to  the  inflamed  muscular  tissue  of 
the  iris  by  a  wide  dilatation  of  the  pupil ;  for  if  the  constrictor  pupillae 
is  not  paralysed,  its  constant  action  in  endeavouring  to  regulate  the  size 
of  the  pupil  according  to  the  stimulus  of  light,  must  of  necessity  tend 
to  increase  the  inflammation,  just  as  would  be  the  case  in  any  other 
inflamed  muscular  tissue,  if  this  could  not  be  kept  perfectly  at  rest. 
3.  The  tension  of  the  eye  will  be  diminished,  and  the  intra-ocular 
circulation  relieved,  which  will  diminish  the  state  of  congestion  of 
the  iris  and  ciliary  body.  Moreover,  the  irritation  of  the  eye  and  the 
ciliary  neuralgia  will  generally  be  alleviated  in  a  very  marked  manner. 
It  is,  however,  absolutely  necessary  that  the  solution  of  atropine  should 
be  of  a  sufl&cient  strength,  and  should  be  energetically  employed.     In 


INFLAMMATION  OF  THE  IRIS.  155 

the  normal  condition  of  the  eye,  an  extremely  weak  solution  (gr.  j. — 3\riij 
of  water)  will  suffice  to  produce  a  wide  dilatation  of  the  pupil,  but  in 
iritis  it  is  very  different.  On  account  of  the  inflamed  and  swollen 
condition  of  the  tissue  of  the  iris,  of  the  lymph  efiused  into  its  meshes, 
and  of  the  hyperasmia,  great  resistance  is  offered  to  the  action  of  the 
atropine  ;  hence  a  very  strong  solution  must  be  used,  and  the  application 
repeated  very  frequently  before  we  can  thoroughly  overcome  this  resist- 
ance. I  am  in  the  habit  of  employing  a  solution  of  from  four  to  six^ 
grains  of  atropine  to  the  ounce  of  water,  and  of  applying  it  at  the  interval 
~or^ve  minules":^  half-an-hour  at  a  time,  this  being  repeated,  if  necessary,  r  '  *^ 
three  or  four  times  a-day,  so  that  altogether  the  atropine  may  have  to 
be  applied  from  eighteen  to  twenty- four  times  a-day,  in  order  to  produce 
and  maintain  a  sufficient^ dilatation  of  the  pupiIT  If  the  case  is  seen 
early,  before  any  adhesions,  or  only  very  slight  and  brittle  ones,  are 
formed,  we  may  generally  succeed  in  producing  a  wide  dilatation  at  the 
end  of  a  few  hours,  and  then  it  is  not  difficult  to  maintain  it.  I  find  that 
patients  apply  the  atropine  with  much  greater  regularity  and  exacti- 
tude, if  they  are  told  to  use  it  for  half-an-hour  at  a  time,  at  intervals 
of  five  minutes,  and  to  repeat  this  at  stated  periods,  three  times  a-day, 
than  if  they  are  only  directed  in  general  terms  to  apply  it  fifteen  or 
eighteen  times  a-day.  As  we  have  frequently  at  the  hospital  to  treat 
even  severe  cases  of  iritis  as  out-patients,  I  invariably  apply  the  atro- 
pine myself  at  the  interval  of  a  few  minutes,  until  either  a  decided  effect 
has  been  produced  upon  the  pupil,  or  the  result  is  negative.  In  the 
former  case,  the  patient  will  himself  experience  the  great  relief  to  the 
pain  and  irritability  of  the  eye  which  has  been  produced  by  the  instil- 
lations, and  will  readily  and  gladly  carry  out  the  treatment  with  regu- 
larity at  home.  Moreover,  the  dilatation  thus  effected  can  generally  be 
maintained  until  the  next  visit,  even  if  the  remedy  is  not  applied  in  the 
interval  quite  as  frequently  as  directed.  I  have  often  been  able  to 
treat  even  severe  cases  of  iritis  with  great  success  by  this  simple  means, 
without  the  employment  of  almost  any  other  remedy,  except  perhaps 
the  use  of  warm  poppy  fomentations ;  the  result  being  a  perfectly 
circular  pupil  without  any,  or  only  the  very  slightest  adhesions.  I 
would  again,  therefore,  urge  in  the  very  strongest  terms  the  energetic 
use  of  atropine  in  iritis,  a  liae  of  treatment  at  present,  unfortunately, 
but  too  much  neglected  in  English  ophthalmic  practice,  the  evil  results 
of  which  neglect  are  constantly  evidenced  by  the  numerous  cases  of 
recurrent  iritis,  chronic  irido-choroiditis,  etc.,  which  we  but  too  fre- 
quently meet  with,  and  which  might  have  been  to  a  very  great  extent 
prevented  by  the  early  and  efficient  use  of  atropine.  It  is  quite  useless 
to  prescribe  a  weak  solution  of  atropine  (gr.  ss — j.  ad  5J)  to  be  used 
a  few  times  in  the  conrse  of  the  day ;  this  cannot  produce  a  dilatation 
of  the  pupU  when  the  tissue  of  the  iris  is  inflamed,  its  effect  will   be 


156  DISEASES  OF   THE   IRIS. 

nil,  as  can  be  easily  seen  by  watcliing  the  state  of  the  pupil  in  cases 
where  such  weak  solutions  are  employed. 

But  we  sometimes  find  that  the  action  of  even  a  strong  solution  of 
atropine,  frequently  applied,  is  resisted,  and  that  it  produces  little  or  no 
effect,  and  increases  rather  than  diminishes  the  irritability  of  the  eye.    In 
such  cases  its  use  must  be  desisted  from  until  the  irritation  is  relieved  by 
the  application  of  a  few  leeches  to  the  temple,  or  perhaps  by  paracentesis 
of  the    anterior    chamber.     This    relief  of  the  inflammatory  irritation 
and  intra-ocular   tension,    permits  of  a  freer  absorption  through  the 
cornea,  and  hence  the  effect  of  atropine  will  now  be  often  very  marked 
and  rapid.     This  effect,  as  Von  Graefe  has  pointed  out,  is  sometimes 
noticed  without  the  re-application  of  the  remedy.     Thus  atropine  may 
have  been  applied  in  cases  of  iritis  or  corneitis  without  producing  any 
dilatation  of  the  pupil,   but  many  hours   afterwards  this  has  ensued 
after   the   application   of  leeches.      We   sometimes  notice,    also,    that 
although  dilatation  of  the  pupil  may  have  been  produced,  yet  that  it 
cannot  be  thoroughly  maintained,  the  atropine  appearing  to  lose  its 
effect.     In  such  cases  it  will  be  found  that  this  likewise  is  due  to  the 
great  irritation  of  the  eye  and  the  increase  in  the  intra-ocular  tension, 
which   prevent   the    absorption   of  the  remedy   through   the   cornea. 
Whereas,  after  the  application  of  leeches  or  the  performance  of  paracen- 
tesis the  atropine  will  again  regain  its   power  over  the  iris.     I  need 
hardly  mention,  that  if  the  pupil  is  firmly  tied  down  by  numerous  and 
thick  adhesions,  the  atropine   should  be  applied  only  in  moderation  in 
order  to  soothe  the  irritability  and   diminish  the  tension  of  the  eye. 
But  if  the  posterior  synechise  are  of  recent  origin,  and  not  very  broad 
and  firm,  but  narrow  and  tongue- Hke,  the  long  continued  use  of  atropine 
often  succeeds  in  tearing  them  through.     But  it  is  often  found  that 
when  this  remedy  is  employed  for  a  considerable  length  of  time  it 
increases  instead  of  aUaying  the  irritability  of  the  eye,  and  may  even 
induce  conjunctivitis  or  acute  granulations.     The  latter  are,  however, 
less  frequently  met  with,  than  a  vascular  condition  of  the  lids  accom- 
panied by  swelling  of  the  conjunctiva  and  great  irritation  of  the  eye. 
In  such  cases  the  atropine  must  be  stopped  at  once,  and  a  mild  astrin- 
gent collyrium  substituted  for  it.    The  strength  and  nature  of  the  latter 
must  vary  with  the  degree  of  conjunctivitis.      A  solution  of  gr.  j  of 
alum,  zinc,  or  nitrate  of  silver  to  the  ounce  of  water  will  be  found  the 
best.     In  vesicular  granulations  a  collyrium  of  vj  to  x  grains  of  borax 
to  1  ounce  of  water  often  proves  of  much  service.     The  irritability  of 
the  eye  may  also  be  allayed  and  the  dilatation  of  the  pupil  tolerably 
maintained  by  the  use  of  a  collyrium  of  belladonna  (Ext.  Bellad.  5ss 
Aq.  dist.  3J),  which  is  to  be  applied  frequently  in  the  course  of  the 
day.       It   is  sometimes  found   that   posterior    synechiee,  which  resist 
the   action  of   atropine,   soon  tear  throvigh   upon    the  application   of 


INFLAMMATION   OF   TIIE   IRIS.  157 

Calabar  bean.     Hence  this  remedy  may  be  tried  alternately  with  the 
atropine. 

The  use  of  atropine  is  to  be  continued  even  for  some  weeks  after 
the  subsidence  of  the  iritis,  so  that  the  wide  dilatation  of  the  pupil 
may  be  maintained  and  the  iris  be  kept  in  a  state  of  rest.  It  has  been 
urged  by  some,  that  the  long  continued  use  of  a  strong  solution  of 
atropine  is  apt  to  produce  a  permanent  dilatation  of  the  pupil  from 
paralysis  of  the  sphincter  pupillae.  But  this  is  a  most  rare  and  excep- 
tional occiuTcnce,  and  if  any  tendency  to  dilatation  should  remain,  it 
may  be  easily  overcome  by  the  occasional  use  of  the  Calabar  bean, 
which  excites  the  action  of  this  muscle.  Although  I  am  in  the 
habit  of  using  atropine  most  extensively  in  the  treatment  of  iritis 
and  other  affections  of  the  eye,  I  have  never  met  with  a  case  in  which 
this  condition  of  permanent  dilatation  was  produced,  nor  have  I  ever 
observed  a  case  of  poisoning  from  the  excessive  use  of  atropine. 
Such  cases  do,  however,  sometimes  occur,  and  are  evidently  produced 
by  the  passage  of  the  atropine  through  the  lachrymal  puncta  to  the 
throat.  The  principal  symptoms  of  poisoning  by  atropine  are  : — great 
increase  in  the  frequency  of  the  pulse,  dryness  of  the  throat,  dysphagia, 
great  irritability  of  the  bladder  and  genital  organs,  impairment  of 
memory,  hallucinations,  and  exciting  dreams.  The  pupils  of  the  eyes 
are  very  widely  dilated.  Generally,  these  symptoms  are  only  moderate 
in  character  when  the  poisoning  has  occurred  in  the  mode  above 
described,  but  their  severity  is  very  great  if  the  atropine  has  been 
swallowed  by  mistake,  and  a  considerable  dose  has  thus  been  taken. 
The  best  and  most  rapid  antidote  is  the  subcutaneous  injection  of  mor- 
phia* (gr.  3-  or  "1;  of  a  grain),  to  be  repeated,  if  necessary, — even  several 
times — at  interva;ls  of  a  few  hours.  The  effect  of  the  remedy  is  very 
marked  and  rapid ;  within  a  few  minutes  the  violence  of  the  symptoms 
has  greatly  subsided,  and  the  patient  is  calm  and  quiet.  To  avoid  the 
danger  of  pjoisoning  Avhen  strong  collyria  of  atropine  are  used  with 
gi-eat  frequency.  Yon  Graefe  recommends  the  patients  to  close  the  eye 
directly  after  the  application,  and  subsequently  on  re-opening  the  eye 
to  wash  it  well.  He  also  sometimes  employs  a  subcutaneous  injection 
of  morphia  at  night,  in  order  to  prevent  all  risk. 

I  have  already  stated  that  we  occasionally  meet  with  persons  whose 
eyes  show  an  extraordinary  antipathy  to  the  use  of  atropine,  and  in 
whom  even  a  drop  of  a  very  weak  solution  suffices  to  produce  great 
irritation  of  the  eye,  and  perhaps  severe  erysipelas  of  the  lids  and  face. 
In  such  cases  it  should  be  stopped  at  once.    My  friend  Dr.  Seeley  of  Cin- 

*  Tide  Dr.  Bell,  Edin.  Med.  Cliir.  Society,  1857,  and  Von  Graefe's  Article, 
"  A.  f.  O.,"  ix,  2,  70  ;  also  a  very  interesting  case  of  severe  Poisoning  by  Atropine, 
reported  by  Dr.  Schmid,  "  Kl.  Monatsbl.,"  1864,  p.  158. 


158  DISEASES  OF   THE   IRIS. 

cinnati  has  informed  me  that  he  has  found  in  such  idiosyncrasies  much 
benefit  from  combining  the  atropine  with  a  weak  solution  of  sulphate 
of  zinc. 

The  severe  ciliary  neuralgia  which  so  often  accompanies  iritis  is  most 
relieved  by  the  application  of  leeches  to  the  temple,  and  the  use  of  hot 
poppy  or  laudanum  fomentations.  The  leeches  should  be  ■  applied 
towards  evening,  so  that  the  nocturnal  exacerbations  may  be  relieved. 
Free  after-bleeding  is  to  be  encouraged  by  the  use  of  hot  fomentations 
or  poultices.  The  nocturnal  pain  and  restlessness  of  the  patient  are  also 
much  alleviated  by  the  use  of  opium,  and  this  remedy  should  never  be 
omitted  in  such  cases,  as  it  is  of  much  consequence  that  the  patient 
should  enjoy  a  good  night's  rest.  I  myself  often  employ  the  sub- 
cutaneous injection  of  morphia  for  this  purpose. 

A  blister  may  be  applied  behind  the  ear,  and  kept  open  for  a  few 
days,  and  the  compound  belladonna  ointment  should  be  rubbed  into 
the  forehead. 

If  there  is  a  considerable  tendency  to  exudation  of  lymph  or  pus 
at  the  edge  of  the  pupil,  into  the  anterior  chamber,  on  the  surface  of 
the  iris  or  into  its  structure,  the  patient  should  be  got  rapidly  under 
the  influence  of  mercury.  One  grain  of  calomel  in  combination  with 
one-fourth  or  one-fifth  of  a  grain  of  opium  should  be  given  every  two 
or  three  hours,  until  salivation  is  produced,  which  will  generally  occur 
in  from  30  to  40  hours  ;  even  when  this  is  produced,  a  slight  degree  of 
tenderness  of  the  gums  should  be  maintained.  I,  however,  greatly 
prefer  the  treatment  by  inunction,  as  the  digestive  powers  are  thus  not 
impaired,  and  the  constitutional  effects  of  the  drug  are,  moreover, 
more  rapidly  and  surely  obtained.  Indeed  I  have  met  with  instances 
in  which  mercury  had  been  given  by  the  mouth  for  some  time,  without 
producing  any  constitutional  efiect,  and  where  this  rapidly  supervened 
upon  inunction.  Half  a  di-achm  or  a  drachm  of  the  strong  mercurial 
ointment  should  be  rubbed  into  the  inside  of  the  arms  and  thighs  two 
or  three  times  daily,  until  the  mouth  becomes  sore.  In  order  to  pre- 
vent the  staining  of  the  skin  the  ointment  may  also  be  rubbed  into  the 
bottom  of  the  feet,  but  here  it  is  absorbed  with  less  rapidity  on  account 
of  the  greater  thickness  of  the  skin.  Mr.  Pridgin  Teale*  recommends 
that  the  mercurial  ointment  should  be  smeared  on  a  broad  piece  of 
flannel  which  is  to  be  wrapped  round  each  arm  of  the  patient,  who 
should  remain  in  bed ;  a  small  quantity  of  fresh  ointment  being 
added  every  night.  In  syphilitic  iritis  with  well  marked  buttons, 
the  use  of  mercury  should  never  be  omitted,  and  I  have  also 
found  much  benefit  in  such  cases  from  the  constant  use  of  hot 
water  compresses,  continued  without  intermission  night  and  day  for 

*  Yide  Mr.  Teale's  interesting  paper,  "  On  tlie  Relative  Value  of  Atropine  and 
of  Mercury  in  the  treatment  of  Acute  Iritis."    "  E.  L.  O.  H.  Reports,"  V,  156. 


INFLAMMATION   OF   THE   IRIS.  159 

several  days.  I  first  saw  tliis  mode  of  treatment  employed  last  year 
by  Dr.  Wecker,  and  soon  afterwards  had  the  opportunity  of  trying  it 
in  a  case  of  syphilitic  iritis  with  numerous  condylomata  of  considerable 
size,  which  had  to  a  great  extent  resisted  the  action  of  mercuiy.  I 
ordered  hot  water  compresses  to  be  applied  to  the  eye  of  as  high  a 
temperature  as  the  patient  could  bear,  and  these  were  changed  every 
few  minutes,  and  continued  for  a  great  part  of  the  day  and  night. 
Within  the  course  of  two  days  the  condylomata  had  diminished  con- 
siderably in  size,  and  within  four  or  five  days  they  had  almost  entirely 
disappeared.  In  another  instance,  the  effect  of  the  compresses  was 
equally  favourable.  Of  course  it  is  only  in  exceptional  cases  that 
this  remedy  can  be  employed,  for  it  requires  the  constant  and  undivided 
attention  of  a  nurse ;  moreover,  few  patients  will  submit  to  the  trouble 
and  inconvenience.  This  remedy  also  greatly  hastens  the  absorption 
of  hypopyon. 

Formerly  it  was  very  much  the  custom  to  place  all  cases  of  iritis 
under  the  influence  of  mercury,  quite  u-respective  of  the  fact  whether 
the  necessity  for  its  use  really  existed  or  not.  Now,  however,  a 
more  rational  mode  of  treatment  obtains,  and  mercury  is  only  used 
in  those  cases  in  which  there  is  much  effusion  of  lymph.  In  specific 
cases  the  iodide  and  bromide  of  potassium,  together  with  the  decoction 
of  bark,  should  be  administered  after  the  use  of  mercury.  Whilst  the 
latter  remedy  is  being  employed,  it  is  also  wise  to  maintain  the  patient's 
strength  by  the  use  of  tonics,  more  especially  preparations  of  steel  and 
quiniae. 

In  the  rheumatic  form  of  iritis  benefit  is  often  experienced  from  the 
use  of  oil  of  turpentine  internally,  as  was  first  recommended  by 
Dr.  Carmichael.  Although  I  have  often  employed  it  with  advantage,  I 
have  frequently  been  obHged  to  give  up  its  use  on  account  of  the 
derangement  of  the  stomach  which  it  produces.  It  should  be  given  iii 
doses  of  from  half  a  drachm  to  one  drachm  two  or  three  times  daily, 
made  into  an  emulsion,  to  which  a  little  carbonate-  of  soda  is  added  to 
prevent  the  derangement  of  the  digestive  organs. 

If  the  aqueous  humour  is  very  cloudy,  or  a  considerable  hypopyon 
is  formed,  paracentesis  should  be  performed  and,  if  necessary,  repeated 
several  times.  The  same  should  be  done  if  the  paia  is  very  severe  and 
does  not  yield  to  the  usual  remedies.  The  broad  needle  should  be  very 
slowly  removed  from  the  anterior  chamber,  so  that  the  escape  of  the 
aqueous  humour  may  not  be  very  sudden,  otherwise  there  may  occur 
great  hypercemia  ex  vacuo  of  the  inner  tunics  of  the  eye.  In  order  to 
facilitate  the  escape  of  the  stringy  portion  of  the  lymph,  the  needle 
should  be  slightly  tilted  sideways,  so  as  to  cause  the  section  to  gape, 
or  the  same  may  be  done  with  a  small  cui^ette  or  probe. 

But   if  the  iritis  is  very  intense  and   obstinate,   resisting  all  our 


160  DISEASES  OF   THE  IRIS. 

remedies,  and  more  especially  if  the  siglit  is  mucli  impaired,  and  there 
are  considerable  firm  synecliiEe,  or  complete  exclusion  of  the  pupil,  and 
if  the  intra-ocular  tension  is  markedly  increased,  a  large  iridectomy 
should  be  made  at  once.  I  have  often  seen  this  produce  the  most 
striking  benefit,  and  it  must  be  remembered  that  if  the  adhesions  be- 
tween the  pupil  and  capsule  are  at  all  considerable  and  broad,  or  there 
is  occlusion  of  the  pupil  from  deposit  of  lymph  within  its  area,  an  iri- 
dectomy will  subsequently  be  necessary,  and  the  condition  of  the  eye 
will  in  all  probability  be  much  worse  when  the  inflammation  has  run  its 
course;  and  hence  the  result  of  an  iridectomy  be  far  less  favourable  than  if 
it  had  been  made  at  an  earlier  period,  before  the  changes  of  structure  had 
attained  any  considerable  degree.  Moreover,  the  iridectomy  generally 
acts  as  the  best  antiphlogistic,  the  inflammation,  which  had  before  resisted 
all  our  remedial  measures,  rapidly  subsiding  after  the  operation. 

In  iritis  serosa  much  benefit  is  often  experienced  from  exciting  the 
free  action  of  the  skin  and  kidneys  by  diaphoretic  and  diuretic  remedies. 
Atropine  should  also  be  applied,  as  well  as  a  suppurating  blister  behind 
the  ear ;  but  it  must  be  confessed  that  local  remedies  often  prove  of 
little  avail.  The  state  of  the  intra-ocular  tension,  of  the  sight,  and  of  the 
field  of  vision  must  bo  narrowly  watched,  and  if  symptoms  of  glaucoma 
supervene,  no  time  should  be  lost  in  making  a  large  iridectomy. 

The  treatment  of  traumatic  iritis  must  vary  according  to  the  nature 
of  the  injury.  If  a  foreign  body  has  become  implanted  in  the  iris,  it 
must  be  carefully  extracted  with  or  without  the  excision  of  the  corre- 
sponding segment  of  the  iris.  If  the  lens  has  also  been  injured  and  a 
traumatic  cataract  has  been  formed,  linear  extraction,  perhaps  combined 
with  iridectomy,  should  be  at  once  performed  if  the  lens  becomes  much 
swollen,  sets  up  great  irritation,  or  the  intra-ocular  tension  is  increased. 
If  a  portion  of  the  iris  prolapses  through  a  small  wound  in  the  cornea, 
it  should  be  pricked  so  that  the  aqueous  humour  may  flow  off,  and  the 
collapsed  protruding  portion  of  iris  should  then  be  excised,  and  a  firm 
compress  applied.  After  an  injury  to  the  iris  the  inflammation  should  be 
combated,  according  to  circumstances,  by  cold  or  hot  compresses,  leeches, 
and  atropine ;  and,  if  necessary,  rapid  salivation  should  be  induced. 

3.— FUNCTIONAL  DISTURBANCES  OF  THE  IRIS. 

(1.)  Mydriasis. 

Although  the  dilatation  of  the  pupil  is  generally  considerable,  it  is 
not  so  extreme  as  that  produced  by  a  strong  solution  of  atropine,  where 
the  iris  is  contracted  to  a  very  narrow,  hardly  perceptible  rim. 
The  dilatation  of  'the  pupil  may  be  uniform  and  regular,  so  that  the 
pupil  retains  its  circular  form,  or  it  may  be  partial  and  irregular,  the 


FUNCTIONAL   DISTURBANCES   OF   THE   IRIS.  IGl 

pupil  thus  acquiring  a  soiucwliat  ovoid  shape.  The  pupil  besides 
being-  dilated,  is  more  or  less  immoveable,  acting  but  slightly  or  not  at 
all  upon  the  influence  of  light,  the  efibrt  of  accommodation,  or  the 
convergence  of  the  optic  axes.  The  sight  is  also  somewhat  affected, 
which  is  due  in  part  to  the  bright  glare  which  is  experienced  on  account 
of  the  wideness  of  the  pupil,  and  also  in  part  to  the  circles  of  diffusion 
formed  upon  the  retina.  If  the  impairment  of  sight  be  simply  due  to 
the  mydi'iasis,  it  will  be  remedied  if  the  patient  looks  through  a  small 
circular  opening  in  a  cai'd  or  through  the  stenopaic  appai^atus,  for  then 
the  glare  will  be  diminished,  and  the  formation  of  circles  of  diffusion 
prevented.  But  very  freqiiently  paralysis  of  the  ciliary  muscle 
co-exists  with  the  dilatation  of  the  pupil,  and  the  impairment  of  vision 
is  chiefly  due  to  the  loss  of  accommodation.  The  features  which 
distinguish  the  symptoms  due  to  loss  of  accommodation  from  those 
which  are  simply  caused  by  mydriasis,  are  frequently  overlooked  by 
medical  men,  and  thus  much  confusion  is  often  produced  in  the  narra- 
tion of  cases.  Nor  is  it  of  unfrequent  occurrence  that  the  symptoms  of 
amblyopia,  produced  by  paralysis  of  accommodation,  are  referred  to 
some  serious  intra-ocular  or  cerebral  lesion.  There  is  not,  however,  a 
necessary  relation  between  the  degree  of  dilatation  of  the  pupil  and 
the  paralysis  of  the  ciHary  muscle,  for  the  pupil  may  be  widely  dilated 
and  the  ciliary  muscle  but  slightly,  if  at  all,  affected  ;  the  converse  is, 
however,  of  less  frequent  occurrence. 

When  the  pupil  is  widely  dilated,  it  no  longer  presents  its  usual 
brilliantly  black  appearance,  but  assumes  a  somewhat  greyish  tint, 
which  is  due  to  the  greater  amount  of  light  reflected  from  the  lens  and 
the  fundus  of  the  eye. 

Mydriasis  is  generally  monocular,  unless  it  is  due  to  some  cerebral 
cause,  or  to  a  deep-seated  intra-ocular  lesion  affecting  both  eyes.  Mon- 
ocular mydriasis  often  produces  considerable  disturbance  of  sight  on 
account  of  the  difference  in  the  brightness  of  the  two  retinal  images, 
and  the  presence  of  circles  of  difiusion.  For  the  purpose  of  accurately 
measuring  the  size  of  the  pupil,  Mr.  Zachariah  Laurence's  "  Pupillo- 
meter"  will  be  found  very  useful. 

Causes. — Before  entering  upon  the  different  causes  which  may  pro- 
duce mydriasis,  it  will  be  well  briefly  to  consider  the  action  of  certain 
substances  upon  the  condition  of  the  pupil  either  in  increasing  or  in 
diminishing  its  size.  Certain  substances,  more  especially  belladonna, 
hyoscyamus,  and  stramonium,  have  the  power  of  producing  a  marked 
dilatation  of  the  pupil,  and  are  hence  termed  tnydriatics.  We 
shall  here,  however,  confine  our  attention  to  the  action  of  atropine 
upon  the  pu[)il  and  the  accommodation.  In  numerous  experiments 
made  by  Bonders,*  it  was  found,  that  if  a  solution  of  four  gi-ains  of 
*  Donders  "  Anomalies  of  Eefraction  and  Accommodation,"  p.  585. 

M 


102  DISEASES   OF   THE   IRIS. 

sulphate  of  atropine  to  an  ounce  of  water  was  applied  to  the  eye,  the 
pupil  began  to  dilate  within  fifteen  minutes,  arriving  at  the  maximum 
degree  of  dilatation  in  from  twenty  to  thirty-five  minutes,  and  finally 
complete  immobility  ensued.  The  younger  the  individual,  and  the 
thinner  the  cornea,  the  more  rapid  was  the  action.  The  diminution  in 
the  power  of  accommodation  commences  somewhat  later  than  the  dila- 
tation of  the  pupil,  but  gradually  returns  together  with  the  mobility  of 
the  pupil  after  some  days.  After  the  lapse  of  forty-two  hours  there  is 
generally  a  slight  diminution  in  the  size  of  the  pupil,  accompanied  by 
some  accommodation,  which  increases  with  tolerable  rapidity  up  to 
the  fourth  day,  but  does  not  become  perfect  till  about  the  eleventh 
day.  The  weaker  the  solution  of  atropine,  the  longer  will  it  take 
to  act,  and  the  less  and  more  transitory  will  be  its  efiect.  By  em- 
ploying an  extremely  weak  solution  (gr.  j.  to  eight  or  ten  ounces  of 
water),  we  may  dilate  the  pupil  without  aflPecting  the  accommodation. 
That  the  action  of  the  atropine  is  due  to  its  absorption  through  the 
cornea,  is  proved  by  the  experiments  of  Von  Graefe,*  who  withdrew 
some  of  the  aqueous  humour  from  the  eye  of  a  rabbit,  the  pupil  of 
which  was  dilated  by  atropine,  and  applying  it  to  the  eye  of  another 
rabbit,  it  was  found  to  produce  dilatation  of  the  pupil. 

The  action  of  the  atropine  appears  to  be  two-fold  ;  it  produces 
dilatation  of  the  pupil,  partly  by  paralysing  the  sphincter  pupillse, 
which  is  supplied  by  the  third  nerve,  and  partly  by  exciting  the 
radiating  fibres  of  the  iins,  which  are  supplied  by  the  sympathetic. 
The  truth  of  this  hypothesis  appears  to  me  to  be  incontrovertibly 
proved  by  Ruete'sf  observation,  that  in  dilatation  of  the  pupil  due  to 
complete  paralysis  of  the  third  nerve,  the  application  of  atropine  pro- 
duced still  further  dilatation.  This  is  certainly  opposed  to  the  theory 
advanced  by  some  observers,  viz.,  that  the  paralysis  of  the  sphincter 
pupillfB  permits  the  sympathetic  nerve  to  exert  an  unopposed  action  in 
dilating  the  pupil.  Moreover,  it  is  found  that  in  mydriasis  due  to  paralysis 
of  the  thii'd  nerve,  the  pupil  is  not  dilated  ad  maximuvi,  even  although 
the  affection  may  have  lasted  some  time ;  but  on  the  application  of 
atropine  the  widest  dilatation  at  once  ensues. 

Calabar  bean  produces  excessive  contraction  of  the  pupil,  together 
with  a  contraction  of  the  ciliary  muscle,  and  an  artificial  myopia.  Its 
action  will  be  more  fully  explained  in  the  article  upon  the  "  Affections 
of  the  Accommodation."  I  think  there  can  be  no  doubt  that  it  chiefly 
produces  its  effect  upon  the  pupil  by  exciting  the  nerves  to  the  spliincter 
pupillse,  although  the  myosis  may  also  be  in  part  due  to  the  paralysis 
of  the  radiating  fibres  of  the  iris  supplied  by  the  sympathetic.     But  the 

*  A.  f.  O.,  I.  1,  462,  note. 

t  Klin  Bcitragc  z.  Pathol,  unci  Physiol,  dor  Augen  and  Ohi'en.  Braunschweig, 
1843. 


FUNCTIONAL   DISTURBANCES   OF   THE   IRIS.  163 

spasmodic  contraction  of  the  ciliary  muscle  speaks  strongly  in  favour 
of  the  excitation  of  the  third  nerve. 

Idiopathic  mydriasis  is  not  unfrequently  due  to  rheumatic  origin, 
the  patient  having  been  exposed  to  cold  or  wet,  and  it  is  in  such  cases 
probably  caused  by  rheumatic  inflammation  of  the  nerve  sheaths.  It 
is  generally  accompanied  by  more  or  less  complete  paralysis,  of  some, 
or  all  the  muscles  supplied  by  the  third  nerve.  It  may  be  also  due  to 
syphilis. 

It  may  likewise  be  caused  by  direct  injuiy  to,  or  compression  of  the 
nerves  supplying  the  constrictor  pupill®,  as  for  instance  in  consequence 
of  severe  blows  upon  the  eye,  or  of  an  increase  in  the  intra-ocular  ten- 
sion. In  those  cases  in  which  it  is  caused  by  a  blow,  the  mydriasis  is 
not  unfrequently  partial,  only  a  certain  portion  of  the  sphincter  pupillas 
being  affected. 

Mydriasis  may  also  be  due  to  ii*ritation  of  the  sympathetic,  as  may 
be  seen  in  certain  spinal  diseases.  The  ephemeral  dilatation  of  the 
pupil  which  occasionally  occurs  for  a  short  time  at  different  periods  of 
the  day  is  also  probably  due  to  this  cause.  Yon  Graefe  has  called 
attention  to  the  interesting  and  important  fact,  that  this  ephemeral 
mydriasis  is  sometimes  a  premonitory  symptom  of  insanity,  more 
especially  of  ambitious  monomania.  The  dilatation  met  with  in  hel- 
minthiasis may  also  be  ascribed  to  irritation  of  the  sympathetic. 

Dilatation  of  the  pupil  is  also  a  common  symptom  in  certain  diseases 
of  the  brain,  e.g.,  meningitis,  hydrocephalus,  and  diseases  of  the  cere- 
bellum, also  in  many  intra-ocular  diseases,  in  which  the  sensitiveness  of 
the  retina  is  much  diminished.  In  exceptional  instances  the  pupil 
may  still  act  perfectly,  even  although  the  eye  is  absolutely  blind.  In 
such  cases,  the  conductibility  of  the  optic  nerve,  and  the  reflex  action 
which  it  produces  on  the  ciliary  nerves  are  unimpaired,  but  the  image 
is  not  perceived  by  the  brain. 

Treatment. — In  the  rheumatic  form  of  mydriasis  a  blister  should  be 
applied  behind  the  ear,  and  iodide  of  potassium,  or  a  preparation  of 
guaiacum  should  be  a,dministered  internally.  I  have,  however,  often 
found  a  far  more  marked  and  i-apid  effect  to  result  upon  the  paralysis 
of  the  accommodation  from  the  application  of  the  blister,  than  upon  the 
mydriasis.  If  the  dilatation  of  the  pupil  does  not  yield  to  these  reme- 
dies, but  shows  a  tendency  to  become  chronic,  tincture  of  opium  should 
be  dropped  into  the  eye,  electricity  should  be  applied,  and  the  use  of 
Calabar  bean  may  be  tried.  The  latter  remedy  should  not  however  be 
applied  of  too  great  a  strength,  or  too  frequently,  otherwise  it  will 
produce  too  much  fatigue  of  the  sphincter  pupillae,  instead  of  simply 
moderately  stimulating  it.  Frequent  and  firm  closure  of  the  eyelids, 
convergence  of  the  optic  axis,  and  repeated  exercise  in  reading,  etc.,  are 
also  of  advantage  in  stimulating  the  contraction  of  the  pupil. 

M    2 


164  DISEASES  OF   THE  IRIS. 

In  very  rare  instances  the  faculty  exists  of  voluntarily  dilating  the 
pupil.  Seitz*  mentions  a  case  of  a  young  student,  who  was  able 
voluntarily  to  produce  a  dilatation  of  about  three  millimetres  by  taking 
a  deep  inspiration,  and  then  holding  his  breath,  at  the  same  time 
making  a  strong  effort,  during  which  the  muscles  of  the  neck  and  back 
become  very  tense.  The  experiment  succeeded  best  when  he  regarded 
an  object  lying  but  a  short  distance  from  the  eye. 

(2.)  Myosis. 

Idiopathic  myosis  is  of  rare  occurrence.  The  pupil  is  in  such  cases 
often  extremely  contracted,  perhaps  to  the  size  of  a  pin's  head,  or  even 
less,  and  acts  but  very  slightly  on  the  stimulus  of  light.  Even  strong 
solutions  of  atropine  produce  biit  a  very  moderate  degree  of  dilatation. 
On  account  of  the  extreme  minuteness  of  the  pupil,  but  little  light 
is  admitted  into  the  eye ;  the  retinal  images  are  consequently  but 
slightly  illuminated,  and  the  vision  on  this  account  more  or  less 
impaired.  The  small  size  of  the  pupil  also  causes  a  considerable 
contraction  of  the  peripheral  part  of  the  field  of  vision. 

The  affection  may  be  caused  by  a  spastic  aflFection  of  the  sphincter 
pupillse,  or  by  a  paralysis  of  the  radiating  fibres  of  the  iris.  The  irrita- 
tion of  the  branch  of  the  third  nerve  which  supplies  the  sphincter  pupillfB 
may  be  due  to  some  central  cause,  or  to  reflex  action  frora  the  fifth  nerve. 
Myosis  may  also  be  produced  by  too  great  and  long  continued  a  use  of 
the  eyes  at  very  minute  objects,  such  as  watch-making,  engraving,  etc. ; 
in  consequence  of  which  the  sphincter  pupillee  in  time  acquires  a  prepon- 
derating power  over  the  dilator.  The  myosis  due  to  paralysis  of  the 
dilator  pupillsp.  is  met  with  in  those  spinal  lesions  in  which  the  sympa- 
thetic nerve  is  affected,  so  that  its  influence  upon  the  radial  fibres  of  the 
iris  is  impaired.  A  tumourf  or  aneurismal  swelling];  pressing  upon  the 
cervical  portion  of  the  sympathetic  may  also  produce  myosis. 

In  the  peculiar  condition  termed  hippus  there  is  a  chronic  spasm  of 
the  iris,  producing  rapid  contractions  and  dilatations  of  the  pupil,  which 
follow  each  other  in  quick  succession  and  are  independent  of  the 
influence  of  light.     It  is  generally  allied  with  nystagmus. 

The  treatment  of  myosis  must  of  course  vary  with  the  cause,  which 
is  often  situated  at  a  distance  from  the  eye.  Periodic  instillations  of 
atropine  should  be  tried,  although  they  generally  have  but  a  slight  and 
only  temporary  effect  upon  the  myosis. 

*  "  Augonheilkundo,"  p.  315. 

t  Willobrand,  A.  f.  O.,  i,  1,  319. 

J  Gaircluer  "  Monthly  Jourual  of  Medicine,"  1855  (vol.  xx,  p.  75). 


WOUNDS   AND   FOREIGN   BODIES   IN   THE   IRIS,  IT)") 


4.— TREMULOUS  IRIS  (IRIDODONESIS). 

The  most  frequent  cause  of  this  condition  is  absence  of  the  lens, 
or  its  pai'tial  or  complete  dislocation.  In  such  cases  the  iris  will  be 
observed  distinctly  to  oscillate  and  tremble  when  the  eye  is  moved  in 
different  directions.  In  cases  of  partial  dislocation  of  the  lens,  the 
tremulousness  will  be  confined  to  that  portion  of  the  iris  which  has  lost 
the  support  of  the  lens. 

This  condition  may  also  be  observed  in  those  cases  of  hydrophthalmas 
in  which  the  size  of  the  anterior  chamber  is  much  increased,  and  the 
iris  is  stretched  sideways,  thus  losing  the  support  of  the  lens. 

It  was  formerly  supposed  that  a  fluid  condition  of  the  vitreous 
humour  produces  undulation  of  the  iris.  That  this  is,  however,  not 
the  case  is  proved  by  the  ophthalmoscope,  for  we  often  meet  with  cases 
in  which  a  fluid  condition  of  a  considerable  portion  or  the  whole  of  the 
vitreous  humour  may  be  diagnosed  frora  the  wide  excursion  made  by 
the  floating  vitreous  opacities,  and  yet  the  iris  does  not  show  the  least 
tendency  to  tremulousness. 


5._W0UNDS  OF  THE  IRIS,  ETC. 

Punctured  or  incised  wounds  of  the  iris  are  not  generally  followed 
by  such  serious  consequences  as  might  have  been  supposed,  as  long  as 
the  lens  has  escaped  injury.  That  the  iris  is  not  very  impatient  of 
such  wounds  is  sufficiently  proved  by  the  operation  of  iridectomy,  or 
the  accidental  incision  of  the  u'is  in  the  performance  of  extraction  of 
cataract,  or  again,  the  puncture  of  the  iris  which  may  occur  during 
the  needle  operation  for  the  solution  of  cataract,  or  the  division  of 
remains  of  opaque  capsule.  Such  operations  are,  as  a  rule,  not  fol- 
lowed by  iritis.  Wounds  which  have  torn  and  dragged  the  iris,  are 
more  dangerous  than  those  which  have  simply  produced  a  clean  cut. 

Blows  upon  the  eye  from  a  blunt  foreign  body,  such  as  a  piece  of 
wood,  a  cork  from  a  ginger-beer  or  soda-water  bottle,  etc.,  may  cause  a 
rupture  of  the  continuity  of  the  iris,  but  more  frequently  still,  a  rupture 
at  its  great  circumference,  tearing  it  away  from  its  ciliary  attachment, 
and  thus  producing  a  more  or  less  extensive  coredialysis.  This  is  the 
more  likely  to  occur  if  the  edge  of  the  pupil  is  tied  down  by  adhesions 
to  the  capsule.  Such  secondary  pupils  may  be  readily  recognised  with 
the  oblique  illumination,  and  still  more  easily  with  the  ophthal- 
moscope, for  the  red  reflex  from  the  fundus  oculi  will  appear  likewise 
tlirough  this  pupil.     Such  accidents,  as  well  as  the  incised  wounds  of 


166  DISEASES  OF   THE   IRIS. 

tlie  iris  are  generally  accompanied  by  more  or  less  eflPusion  of  blood  into 
the  anterior  chamber. 

Mr.  Lawson*  narrates  an  extraordinary  case  of  "  laceration  of  the 
iris,  without  injury  to  any  of  the  external  coats  of  the  eye  from  the 
splash  of  a  bullet,  after  it  had  hit  the  target,  striking  the  eye,"  which 
was  under  the  care  of  Mr.  Critchott.  The  external  coats  of  the  eye 
were  quite  uninjured,  and  the  outer  part  of  the  cornea  only  presented 
a  slight  unevenness  of  its  epithelial  surface,  without,  however,  showing 
any  opacity  or  any  mark  indicating  the  point  which  received  the  blow. 
On  looking,  however,  within  the  eye,  two  distinct  pupils  are  at  once  seen, 
the  one  immediately  above  the  other ;  the  lower  is  separated  from  the 
upper  one  by  a  bridge  of  iris  ;  and  the  upper  pupil  is  bounded  by  a 
border  of  iris,  so  that  it  is  distinct  from,  and  does  not  encroach  on  the 
ciliary  attachment  of  the  iris.  The  margins  of  the  new  pupil  when 
carefully  examined  are  found  to  be  slightly  lacerated  and  irregular. 

Cases  of  rupture  of  the  smaller  circle  of  the  iris  accompanied  by 
dilatation  of  the  pupil  have  been  narrated  by  Mr.  White  Cooper. 
Wecker  has,  however,  seen  a  case  in  which  the  sphincter  pupillse  was 
ruptured  from  a  violent  blow  upon  the  eye,  without  any  consecutive 
dilatation  of  the  pupil. 

A  very  peculiar  and  rare  condition  is  that  of  retraction  or  depres- 
sion of  a  portion  of  the  iris,  which  is  sometimes  produced  by  blows 
upon  the  eye.  The  portion  of  the  iris  which  is  depressed  is  folded  back 
ujoon  itself,  and  the  inner  pupillary  circle  disappears  at  the  point  where 
this  folding  occurs,  the  peripheral  portion  of  the  iris  is  quite  unapparent, 
having  sunk  back  out  of  sight,  so  that  the  eye  at  this  point  presents 
the  a^^pearance  as  if  an  iridectomy  had  been  made  quite  up  to  the 
ciliary  attachment.  On  examining  the  eye  with  the  oblique  illumina- 
tion, or  with  the  ophthalmoscope,  we  cannot,  however,  detect  a  trace 
of  the  ciliary  processes,  as  would  be  the  case  if  the  iris  had  been 
removed. t 

In  such  cases  the  lens  has  generally  been  found  partially  dislocated 
or  much  diminished  in  size. 

The  treatment  of  injuries  to  the  iris  must  be  directed  to  diminishing 
any  inflammatory  symptoms  which  may  supervene.  Atropine  should 
be  fi-equcntly  dropped  into  the  eye,  leeches  should,  if  necessary,  be 
applied  to  the  temple,  and  for  the  first  few  hours  after  the  accident, 
cold  compresses  will  afford  great  relief  and  assist  in  checking  a  tendency 
to  inflammation.  If  there  is  any  prolapse  of  the  iris  through  the  cor- 
neal wound,  or  if  the  lens  has  been  injured,  the  treatment  laid  down 

*  "  Injuries  of  the  Eye,  Orbit,  etc.,"  p.  123. 

+  For  a  descrijition  of  cases  of  this  interesting  affection,  vide  "  Mooreu's  Opli- 
thahniatrische  JJeobachtungen,"  p.  131,  and  Wecker's  "  Traite  des  Maladies  des 
Yeux,"  Tol.  i,  p.  425. 


TUMOURS   OF   THE   IRIS.  167 

in  the  articles  upon  "  Wounds  of  tlie  Cornea"  and  "  Traumatic  Cataract" 
must  be  pui"sued. 

Small  foreign  bodies,  such  as  splinters  of  steel  or  glass,  portions  of 
gun-cap,  etc.,  m9,y  become  lodged  in  the  iris,  or  may  injure  it  in  their 
passage  to  the  back  of  the  eye.  The  presence  of  even  a  minute 
foreign  body  in  the  tissue  of  the  iris  is  a  source  of  constant  irritation, 
and  consequently  soon  sets  up  more  or  less  severe  inflammatory  com- 
plications, giving  rise  to  corneo-iritis,  or  perhaps  suppurative  irido- 
choroiditis.  It  is,  therefore,  most  advisable  to  extract  a  foreign  body 
in  the  iris  as  soon  as  possible.  The  best  mode  of  doing  this  is  by  an 
iridectomy,  the  segment  of  iris  in  which  the  foreign  body  is  lodged 
being  excised. 


6.— TUMOURS  OF  THE  IRIS,  ETC. 

Cysts  of  the  iris  are  comparatively  a  rare  affection,  and  are  almost 
always  the  result  of  some  injury  to  the  iris.  Thus  they  have  been  met 
with  after  the  lodgement  of  foreign  bodies  in  the  iris,  penetrating  or 
incised  wounds  of  the  latter,  blows  upon  the  eye,  or  even  after  opera- 
tions for  cataract,  such  as  the  operation  of  division  or  the  common  flap 
extraction.  Sometimes  it  is  difiicult  to  discover  the  exact  cause,  or  to 
ascertain  with  certainty  that  any  accident  has  ever  occurred  to  the  eye. 
In  such  cases,  a  very  careful  examination  may,  however,  sometimes 
lead  us  to  detect  a  slight  opacity  of  the  cornea,  the  remains  of  a  former 
perforation. 

The  cysts  genei^ally  appear  in  the  form  of  small  transparent  vesicles, 
situated  on  th.e  surface  of  the  iris,  from  which  they  may  spring  from  a 
broadish  base,  or  a  little  pedicle.  Their  contents,  instead  of  being 
limpid  and  transparent,  may  be  opaque,  causing  the  cyst  to  assume  the 
appearance  of  a  little  pearl.  Von  Graefe*  records  a  case  in  which  the 
contents  were  sebaceous,  soft,  and  pulpy,  and  in  this  cyst  there  were 
also  found  a  number  of  short  thick  hairs.  A  similar  case  is  described 
by  Mr.  White  Cooper,t  but  in  this  the  cyst  was  tough  and  hard,  like 
cartilage,  and  was  torn  away  bit  by  bit  with  the  canula  forceps.  The 
little  growth  appeared  to  be  made  up  of  epithelial  cells,  closely  packed 
together. 

The  presence  of  the  cyst  may  not  be  productive  of  any  particular 
inconvenience  or  impairment  of  the  sight,  except  inasmuch  as  the 
latter  may  be  interfered  with  by  the  cyst  protruding  more  or  less  into 
the  area  of  the  pupil.  But  in  other  cases  it  sets  up  a  considerable 
degree  of  irritation,   accompanied   by  ciliary   injection,  photophobia, 

*  A.  f.  O.,  iii,  2,  412. 

t  "  London  Journal  of  Medicine,"  Sept.,  1852. 


168  DISEASES   OF   THE  IRIS. 

laclirymation,  etc.,  or  it  may  even  give  rise  to  iritis.  In  a  case  narrated 
by  Mr.  Hulke*  sympathetic  inflammation  of  the  other  eye  was  set  up, 
which  yielded  rapidly  after  the  excision  of  the  cyst. 

In  an  interesting  paper  upon  cysts  of  the  u'is,  Mr.  Hulke  says : — 
"  An  examination  of  all  the  cases  which  I  have  been  able  to  collect 
shows  :  I.  that  cysts,  in  relation  with  the  iris  projecting  into  the  anterior 
chamber,  originate  in  two  situations — 1,  in  the  iris ;  and  2,  in  connec- 
tion with  the  ciliary  processes.  The  first  lie  between  the  uveal  and 
the  muscular  stratum  of  the  iris,  and  are  distinguished  by  the  presence 
of  muscular  fibres  upon  their  anterior  wall ;  the  second  lie  behind  the 
iris,  and  bear  the  uveal  as  well  as  the  muscular  strata  on  their  front. 
II.  It  also  shows  that  these  cysts  are  of  more  than  one  kind ;  that  there 
are — 1,  delicate  membranous  cysts,  with  an  epithehal  lining,  and  clear 
limpid  contents ;  2,  thick  walled  cysts,  with  opaque  thicker  contents 
(whether  these  are  generically  distinct  from  I  we  are  not  yet  in  a 
position  to  determine,  but  it  seems  probable  that  they  are  so)  ;  3,  solid 
cystic  collections  of  epithelium,  wens  or  dermoid  cysts  ;  4,  cysts  formed 
by  deliquescence  in  myxomata." 

The  tissue  of  the  iris  covering  the  anterior  cyst- wall  generally 
becomes  so  stretched  and  attenuated,  that  the  limpid  contents  of  the 
latter  are  perfectly  distinguishable,  and  we  can  often  see  quite  through 
it  to  the  posterior  wall. 

The  best  mode  of  treatraent  is  the  excision  of  the  cyst,  together 
with  the  segment  of  the  iris  to  which  it  is  attached.  Puncturinar  or 
laceration  generally  proves  unsuccessful,  as  the  cyst  very  rapidly  re- 
fills. But  its  excision  combined  with  iridectomy  is  not  always  free 
from  danger,  as  was  shown  in  a  case  of  Von  Graefe's,t  where  the  opera- 
tion was  followed  by  severe  purulent  cyclitis  ;  probably  from  a  portion 
of  the  cyst  having  been  left  behind,  and  becoming  the  source  of  the 
inflammatory  complications. 

Cysticerci  of  the  iris  will  be  treated  of  in  the  article  upon  "  The 
changes  in  the  contents  of  the  Anterior  Chamber." 

Ncevi  of  the  ii'is  are  almost  always  congenital,  and  present  the  ap- 
pearance of  small  black  patches  or  elevations,  which  remain  stationary 
and  cause  no  irritation. 

Teleangiectasis  or  nsevus  of  the  iris  is  an  extremely  rare  affection. 
MoorenJ  describes  a  very  extraordinary  case  of  this  kind  in  which  a 
dark  tumour,  resembling  a  blackberry  in  size  and  appearance,  was 
situated   on   the   external    portion    of  the   iris,    extending    somewhat 

*  "  R.  L.  O.  H.  Rep.,"  vi,  p.  12. 

t  A.  f.  O.,  xii,  2,  230. 

X  "  Oplithal.  Beobaclitungen,"  p.  125. 


TUMOURS   OF   THE   IRIS.  169 

into  the  pupil,  without,  however,  in  the  least  impairing  the  sight.  The 
tumour,  whose  anterior  surface  touched  the  cornea,  was  traversed  by- 
several  dilated  blood-vessels,  which  could  be  seen  to  shine  through  from 
the  rusty  brown  back  ground  of  the  growth  in  the  form  of  bright  red 
wavy  lines,  to  be  again  lost  in  it  after  a  short  course.  The  ophthal- 
moscope did  not  reveal  the  slightest  change  in  the  fundus.  The  most 
extraordinary  feature  of  the  case  was  that  when  the  patient,  after  having 
shaken  his  head,  stooped  rapidly  forward,  the  whole  anterior  chamber 
became  filled  with  light  coloured  blood.  The  sight  (which  was  a  few 
moments  before  perfectly  good)  was  at  once  I'educed  to  a  mere  percep- 
tion of  the  difference  between  light  and  dark.  When  the  patient  had 
held  his  head  still  for  a  few  seconds ,  the  haemorrhage  began  at  once  to 
disappear,  the  upper  portion  of  the  iris  became  apparent,  then  the 
upper  part  of  the  pupil,  and  so  on,  until  in  the  course  of  about  a  minute 
and  a  half  every  trace  of  the  haemorrhage  had  vanished,  and  the  sight 
had  resumed  its  normal  standard.  Each  repetition  of  the  experiment 
produced  the  same  astonishing  phenomena,  nor  was  Mooren  able,  in 
spite  of  the  most  careful  and  minute  examination,  to  detect  the  source 
of  the  hasmorrhage.  The  excision  of  the  tumour  was  proposed,  but 
refused  by  the  patient.  Four  years  later  he  again  presented  himself, 
the  appearances  of  the  eye  having  in  the  meantime  undergone  a  con- 
siderable change.  The  haemorrhage  had  entirely  disappeared  since 
about  a  year,  the  tumour  had  become  reduced  to  about  one- third  of  its 
original  size,  its  colour  had  assumed  a  dirty  grey  tint,  and  instead  of 
the  dilated  vessels,  numerous  isolated  black  deposits  of  pigment  were 
now  apparent.  The  intra-ocular  tension  had  increased,  and  the  sight 
diminished,  to  the  spelling  with  difficulty  letters  of  16,  and  the  field  of 
vision  was  contracted.  There  was  slight  excavation  of  the  optic  nerve. 
The  patient  again  refused  an  iridectomy.  Some  months  later,  the  glau- 
comatous changes  having  led  to  a  complete  loss  of  sight,  the  patient 
submitted  to  an  iridectomy,  on  account  of  the  very  severe  ciliary  neu- 
ralgia which  had  supervened.  The  little  shrunken  tumour  was  sent  to 
Dr.  Schweigger  for  examination,  who,  as  Mooren  says,  doubtlessly  did 
not  receive  it,  as  its  receipt  was  never  acknowledged  by  him.  The 
other  eye  was  subsequently  affected  with  sympathetic  irido-choroiditis, 
which  yielded  to  an  iridectomy. 

Ca/ncer  of  the  ii'is  is  almost  always  due  to  an  extension  of  the  disease 
from  the  deeper  tunics  of  the  eye ;  it  is  extremely  rare  as  a  primary 
affection  of  the  iris,  and  is  then  generally  melanotic  in  character.  It 
appears  in  the  form  of  a  small  dark  yellowish-brown  elevation  or 
tubercle  at  one  point  of  the  iris,  perhaps  somewhat  resembling  a  little 
syphiUtic  button  or  condyloma.  The  tumour  may  remain  stationary 
for  a  length  of  time,  or  rapidly  increase  more  and  more  in  size,  and  pro- 


170  DISEASES  OF  THE  IRIS. 

trude  into  tlie  anterior  chamber  in  the  form  of  a  dark  bro^Ti  or  blackish 
mass,  which  either  perforates  the  cornea  or  the  anterior  portion  of  the 
sclerotic,  which  becomes  staphylomatous  at  this  point,  and  gradually 
yielding,  the  tumour  sprouts  forth.  As  soon  as  the  true  nature  of  the 
disease  is  recognised,  no  time  should  be  lost  in  excising  the  eyeball. 
This  is  much  wiser  than  removing  only  the  anterior  half  of  the  eye,  as 
a  similar  disease  may  exist  in  the  deeper  tunics. 


7._C0NGEN"ITAL  ANOMALIES  OF  THE  IRIS. 

Congenital  Irideremia,  or  absence  of  the  iris,  is  occasionally  hereditary. 
I  have  seen  one  instance  in  which  the  iris  was  completely  wanting 
in  both  eyes  of  the  father,  this  condition  being  accompanied  by  a  partial 
luxation  and  opacity  of  the  crystalline  lenses  ;  and  in  the  son  (an  infant 
of  a  few  months  old)  there  was  total  ii'idemia  in  both  eyes,  but  the  latter 
appeared  otherwise  quite  normal.  Sometimes  the  iris  is  not  completely 
wanting ;  a  small  rudimentary  portion  of  varying  size,  being  apparent 
at  the  periphery.  Absence  of  the  iris  is  often  accompanied  by  opacity 
or  displacement  of  the  lens,  nystagmus,  and  imperfect  development  of 
the  cornea,  which  perhaps  does  not  acquire  its  normal  size.  The  power 
of  accommodation  may  also  be  impaii'ed,  but  this  is  not  due,  as  was  for- 
merly supposed,  to  the  absence  of  the  iris,  but  may  be  caused  by  an 
arrest  in  the  development  of  the  ciliary  body.  In  those  cases  in  which 
iridemia  is  not  accompanied  by  any  other  affection,  the  sight  may  be 
very  good,  more  especially  if  the  "glare  of  the  light  and  the  circles  of 
diffusion  upon  the  retina  are  diminished  by  the  use  of  stenopaic  spec- 
tacles. 

CoJohonia,  or  partial  deficiency  of  the  iris  (cleft  iris),  is  almost 
always  accompanied  by  a  cleft  in  the  ciliary  body  and  choroid.  It  is 
due  to  an  arrest  in  the  development  of  the  iris,  and  may  vary  very  much 
in  size  and  shape.  The  coloboma  is  generally  situated  at  the  lower,  or 
lower  and  inner  portion  of  the  iris,  and  is  irregularly  triangular  or 
pyriform  in  shape,  the  base  of  the  triangle  being  turned  towards  the 
pupU,  the  apex  towards  the  periphery.  Coloboma  of  the  iris  generally 
affects  both  eyes ;  sometimes  it  is  confined  to  one,  generally  the  left, 
and  is  often  accompanied  by  other  congenital  anomalies  of  the  eye, 
such  as  cleft  of  the  eyelids,  congenital  cataract,  microphthalmos, 
nystagmus,  cleft  palate,  etc.  The  fissure  in  the  iris  does  not  neces- 
sarily extend  quite  up  to  the  periphery,  but  at  the  latter  point  a  margin 
of  iris  may  exist,  uniting  the  two  edges  of  the  cleft.  Moreover,  the 
area  of  the  coloboma  may  be  closed  by  a  rudimentary,  darkly  pigmented 
membrane,  which  might  cause  the  deficiency  of  the  iris  at  this  point 
to  be  altogether  overlooked  by  a  superficial  observer  (Seitz).     If  the 


CONGENITAL  ANOMALIES  OF   THE   IRIS.  171 

fibrous  layer  of  the  iris  is  deficient  to  a  greater  extent  than  the  uveal 
layer,  the  edge  of  the  cleft  is  fringed  with  a  distinct  black  margin.  In 
simple  coloboma  iridis  the  aciuty  of  vision  is  generally  not  at  all 
affected  ;  it  may  be  very  different,  however,  if  the  affection  is  associated 
with  a  considerable  cleft  in  the  ciliary  body  and  choroid. 

Amongst  the  other  congenital  anomalies  of  the  iris,  we  must  call 
attention  to  the  eccentric  position  of  the  pupil  (^coredopia),  and  to  the 
case  in  which  there  exists  more  than  one  pupil  {fohjcoHa).  The  eccen- 
tric displacement  of  the  pupil  may  sometimes  be  so  slight  that  it  is 
hardly  observable,  but  in  other  cases  it  is  well  marked,  there  being 
only  perhaps  a  small  rim  of  iris  at  the  side  towards  which  the  pupil  is 
displaced.  Sometimes  both  eyes  are  affected,  and  then  the  displace- 
ment of  the  pupil  may  be  symmetrical.  I  have,  at  the  present  time, 
under  my  care  at  the  Royal  London  Ophthalmic  Hospital,  two  very 
interesting  cases  of  corectopia,  occurring  in  two  sisters.  In  each  eye 
the  pupil  is  displaced,  and  the  lens  is  also  dislocated,  both  these  con- 
ditions being  congenital.     The  eyes  of  the  parents  are  quite  normal. 

In  cases  of  pohjcoria  a  second  pupil  may  exist  at  some  little  dis- 
tance from  the  original  one,  being  separated  from  it  by  a  more  or  less 
considerable  band  of  iris,  the  second  pupil  being,  in  fact,  a  partial  colo- 
boma (annular)  of  the  iris.  In  other  cases  several  small  pupils  exist 
near  the  normal  one,  being  separated  from  it  and  each  other  by  narrow 
trabeculge  of  iris,  and  this  condition  is  evidently  closely  allied  to  that 
of  persistent  pupillary  membrane.  The  existence  of  two  or  more  pupils 
does  not  generally  produce  any  impairment  of  sight,  or  give  rise  to 
monocular  diplopia  or  polyopia. 

Persistence  of  the  pupillary  membrane  is  a  rare  affection,  and  is 
characterised  by  the  presence  of  one  or  more  delicate  fibrillar  bands, 
springing  from  the  larger  circle  of  the  ii'is,  and  passing  over  the 
smaller  circle  into  the  pupil,  which  they  may  either  cross  to  be  inserted 
at  the  other  side  into  the  larger  circle  of  the  iris,  or  they  may  pass  over 
into  a  thin,  pigmented,  circumscribed  membrane,  situated  in  the  area 
of  the  pupil  and  perhaps  attached  to  the  capsule  of  the  lens.  These 
large  trabeculae  are  often  connected  to  each  other  by  numerous  cross- 
bars of  delicate  fibrillae.*  Weberf  has  described  a  very  interesting 
case,  in  which  the  fibres  formed  a  series  of  arcades.  The  fibrilla)  were 
very  thin  and  delicate,  and  were  about  18  or  20  in  number,  and  united 
by  numerous  thin  fibrillar  cross-bars.  They  sprung  from  the  larger 
circle  of  the  iris,  and  passed  straight  over  the  lesser  circle  to  the  centre 
of  the  pupil,    which    was   occupied    by  a   circumscribed,    pigmented, 

*  For  several  interesting  eases  of  tlds  affection,  as  well  as  for  a  brief  resume  of 
the  cases  hitherto  described  in  ophthalmic  literature,  vide  two  articles  of  Cohn's  in 
"  KI.  Monatsbl."  1867,  pp.  62  and  119. 

t  A.  f.  O.,  Tiii,  1,  337. 


172 


DISEASES  OF   THE  IRIS. 


membranous  patch,  firmly  attached  to  the  capsule  of  the  lens.  Into 
this  membrane  the  fibrillce  were  inserted.  The  remaining  portion 
of  the  capsule,  as  well  as  the  edge  of  the  pupil,  were  quite  free  from  any 
deposits  or  adhesions,  and  the  pupil  acted  perfectly  under  the  influence 
of  light.  It  appears  probable  that  these  remains  of  the  pupillary  mem- 
brane are  more  frequent  in  young  children,  giving  way  and  disappearing 
as  the  person  gets  older.  Their  true  nature  is,  moreover,  sometimes 
overlooked,  they  being  mistaken  for  simple  adhesions  between  the  pupil 
and  the  capsule  of  the  lens. 


Fig.  12. 


8.— OPERATIONS  FOR  ARTIFICIAL  PUPIL. 

It  is  unnecessary  to  enter  into  a  description  of  the  various  modes 
of  making  an  artificial  pupil  which  have  been  in  vogue  at  different 
times,  as  they  have  now  been  all  abandoned  in  favour  of  the  following 
operations,  of  which  that  of  iridectomy  enjoys  by  far  the  widest  and 
most  varied  application,  and  hence  demands  at  our  hands  the  most  full 
and  exact  description. 

(1.)  IRIDECTOMY. 

The  following  instruments  are  required  for  the  operation : — 
1.  A  silver  wire  speculum  for  keeping  open  the  eyelids.  Weiss's 
stop-speculum  (Fig.  12)  will  be  found  the  best,  as  by  means  of  an  easily- 
adjustable  screw,  it  permits  the  eyelids  to 
be  kept  fixedly  apart  at  any  desired  distance, 
so  that  they  cannot  press  the  branches  to- 
gether, and  thus  narrow  the  aperture.  This 
form  of  speculum  is  seen  in  Fig.  12.  If 
the  patient  should  strain  very  much,  and  the 
speculum  presses  upon  the  eyeball,  an  assist- 
ant should  lift  it  forward  a  little,  so  as  to 
remove  it  from  the  globe. 

2.  A  pair  of  fixing  forceps  for  steadying 
the  eyeball.  They  must  catch  accurately, 
and  the  tooth  should  not  be  too  sharp  and 
pointed,  otherwise  it  will  easily  tear  through 
the  conjunctiva.  If  the  latter  is  thin  and 
rotten  (as  is  often  the  case  in  elderly  per- 
sons) Waldau's  fixation  forceps  are  to  be 
preferred,  which,  instead  of  being  toothed 
are  finely  serrated,  so  that  they  obtain  a 
firm  hold  of  the  conjunctiva  without  tearing  through  it. 

3.  A  broad  lance-shaped  knifq.     It  should  be  about  the  same  width 


IRIDECTOMY. 


173 


as  that  represented  in  Fig.  13.  If  it  is  much  broader  the  internal 
wound  will  be  considerably  smaller  than  the  external,  and  in  order  to 
enlarge  it  to  the  same  size  as  the  latter,  the  edge  of  the  knife  must  be 
much  tilted  in  withdrawing  the  instrument  from  the  anterior  chamber. 
But  this  proceeding  is  often  somewhat  difficult,  and  may  prove  dangerous 
in  the  hands  of  an  inexperienced  operator.    The  shape  of  the  knife  must 


Fig.  13. 


Fig.  11.. 


vary  with  the  direction  in  which  the  ii'idectomy  is  to  be  made.  If  it 
is  m.ade  outwards  (to  the  temporal  side)  the  straight  knife  is  to  be  used. 
But  if  the  iridectomy  is  made  inwards  or  upwards,  the  blade  must  be 
bent  at  a  more  or  less  acute  angle  (Fig.  14),  according  to  the  promi- 
nence of  the  nose  or  of  the  upper  edge  of  the  orbit.  If  the  anterior 
chamber  is  extremely  shallow,  so  that  the  iris  is  nearly  in  contact  with 
the  coi'nea,  and  especially  if  the  pupil  is  at  the  same  time  dilated,  it 
will  be  better  to  make  the  incision  wdth  Von  Graefe's  narrow  cataract 
knife  than  the  lance-shaped  one.  For  with  the  former  we  can  skirt 
the  edge  of  the  anterior  chamber,  and  make  a  large  incision  without 
any  risk  of  wounding  the  lens. 

4.  The  iris  forceps  should  catch  most  accurately,  and,  when  closed, 
should  be  perfectly  smooth  at  the  extremity ;  for  if  they  are  rough 
and  irregular  they  will  scratch  and  tear  the  iris  and  the  lips  of  the 
incision,  and  thus  perhaps  set  up  some  irritation.  They  may  be 
straight  (Fig.  15)  when  the  iridectomy  is  made  outwards,  although  I, 
even  here,  prefer  to  have  them  slightly  bent.  For  the  upward  or  in- 
ward operation  they  must  be  bent  at  a  still  more  acute  angle  (Fig.  16). 

5.  The  iris  scissors  (Fig.  17)  should  be  bent  at  an  angle,  and, 
though  sharp,  should  not  be  too  finely  pointed.  Care  should  be  taken 
that  the  blades  close  tightly,  and  do  not  over-ride  each  other,  which 
may  easily  occur  in  such  slight  scissors,  if  the  joint  is  not  sufficiently 


174 


DISEASES   OF   THE  IRIS. 


strong  and  fii'm.     Instead  of  these,  a  pair  of  scissors   curved  on  the 
flat  (as  shown  in  Fig.  19,  p.  175)  may  also  be  used. 


Fig.  16 


Fig.  17. 


The  operation  is  to  be  performed  in  the  following  manner : — The 
patient  is  to  be  placed  in  the  recumbent  position,  either  in  bed  or 
on  a  couch,  the  head  being  slightly  elevated.  Unless  there  be  very 
exceptional  reasons  to  the  contrary,  chloroform  should  always  be 
administered.  I  prefer  to  use  it  in  all  cases  of  iridectomy,  especially  if 
the  eye  is  acutely  inflamed,  for  the  operation  is  then  often  very  painful : 
and,  however  courageous  and  determined  the  patient  may  be,  he  may 
find  it  impossible  to  control  some  sudden,  involuntary  movement  of  the 
eye  or  head,  which  may  endanger  the  result  of  the  operation,  or  even 
imperil  the  safety  of  the  eye.  But  if  chloroform  is  employed,  it 
should  be  given  so  as  to  antesthetise  the  patient  completely,  and  render 
him  quite  passive,  otherwise  he  may  prove  far  more  unruly  than  if 
none  had  been  administered ;  and  the  operation  is  of  so  delicate  a 
nature  that  absolute  quietude  of  the  eye  is  necessary.  If  sickness 
should  supervene,  the  farther  steps  of  the  operation  must  be  delayed 
until  this  has  passed  away. 


IRIDECTOMY. 


175 


Fig.  18. 


Let  us  now  suppose  that  an  outward  iridectomy  is  to  be  performed 
upon  the  right  eye  for  the  cure  of  glaucoma.  If  the  operator  is  ambi- 
dexter, he  may  seat  himself  upon  the  couch  or  bed  in  front  of  the 
patient,  and  make  the  incision  with  liis  left  hand.  If  not,  he  should 
place  himself  behind  the  patient.  The  eyelids  having  been  opened  to 
the  desired  extent  by  the  stop-speculum,  the  operator  should  seize  with 
a  pair  of  fixing  forceps  the  conjunctiva  near  the  inner  side  of  the  cornea, 
exactly  opposite  to  the  place  where  the  incision  is  to  be  made.  The 
straight  iridectomy  knife  is  then  to  be  thrust  into  the  sclerotic,  about 
half  a  line  from  the  sclero- corneal  conjunctiva  (Fig.  18),  and  the  handle 
of  the  instrument  being  laid  well  back 
towards  the  temple,  the  point  is  to  be 
passed  into  the  anterior  chamber  at  its 
very  rim,  and  carried  on  slowly  and 
steadily  towards  the  opposite  side  until 
the  incision  is  of  the  desired  extent. 
The  knife  is  then  to  be  slowly  and  gently 
withdrawn,  the  aqueous  humoui'  being 
allowed  to  flow  off  as  slowly  as  possible, 

so  that  the  relief  of  the  intra- ocular  pressure  may  not  be  sudden,  other- 
wise this  wiU  cause  a  rapid  over- filling  of  the  intra-ocular  blood-vessels, 
and  perhaps  a  rupture  of  the  capillaries  of  the  retina  and  choroid, 
producing  sometimes  very  extensive  heemorrhage.  When  the  knife  has 
been  nearly  withdrawn  from  the  anterior  chamber,  the  handle  is  to  be 
somewhat  depressed,  so  that  the  upper  edge  of  the  blade  is  slightly 
elevated,  and  the  upper  angle  of  the  internal  incision  should  then  be 
enlarged  to  a  size  corresponding  to  the  external  incision.  The  same 
proceeding  may  be  repeated  downwards,  or  the  incision  may  be 
enlarged  to  the  required  extent  with  a  pair  of  blunt-pointed  scissors 
curved  on  the  fiat,  the  one  point  being  introduced  just  within  the 
anterior  chamber,  and  the  incision  then  enlarged  vipwards  and  down- 
wards. 

On  the  completion  of  the  section,  the  forceps  are  to  be  handed  over 
to  an  assistant,  who  should,  if  neces- 
sary, fix  the  eye,  being  careful  at  the 
same  time  not  to  press  or  drag  upon 
the  eyeball,  but  simply  to  rotate  it 
gently  in  its  bed.  If  the  iris  does  not 
protrude  through  the  Kps  of  the  wound, 
the  operator  should  pass  the  iris  for- 
ceps (closed)  into  the  anterior  chamber, 
and  then,  opening  them  somewhat 
widely,  he  should  seize  a  fold  of  the 
iris,  and  draw   it   gently  throagh   the 


Fig.  19. 


176 


DISEASES  OF   THE  IRIS. 


Fig.  20. 


incision  to  the  requisite  extent,  and  cut  it  off  with  the  scissors  quite 
close  to  the  lips  of  the  wound  (Fig.  19).  The  excision  of  the  iris  may- 
be done  either  by  the  operator  himself,  or  by  an  assistant.  In  the 
former  case  the  iris  forceps  should  be  held  ia  the  left  hand,  and  the 
scissors  in  the  right,  as  it  requires  some  practice  to  use  the  latter  well 
with  the  left  hand.  If  a  portion  of  the  iris  protrudes  into  the  incision, 
there  will  be  no  occasion  to  introduce  the  forceps  into  the  anterior 
chamber,  but  the  prolapsed  portion  is  to  be  seized,  and,  if  necessary, 
drawn  forth  somewhat  further  and  divided. 

The  portion  of  iris  may  be  excised  by  one  cut,  or  else  this  may  be 
done  according  to  either  of  the  following  modifications  introduced  by 
Mr.  Bowman. 

The  protruding  portion  of  iris  may  be  drawn  to  the  right-hand 
angle  of  the  incision,  and  partly  divided  close  up  to  the  angle,  the 
other  portion  being  then  gently  torn  from  its  ciliary  insertion  (slight 
snips  of  the  scissors  aiding  in  the  division),  and  drawn  to  the  opposite 
angle,  to  be  there  completely  cut  off.  This  mode  of  operating  is  illus- 
trated ia  Fig.  20,  a,  the  prolapse  drawn  down  to  the  lower   (right 

hand)  angle,  a,  of  the  incision,  where  the 
inferior  portion  is  to  be  divided,  and  the 
other  drawn  up  in  the  direction  of  b,  to  the 
upper  angle  of  the  incision. 

Or  again  the  prolapse  (Fig.  21,  a),  may 
be  divided  into  two  portions  at  b.  The 
lower  portion  is  to  be  drawn  in  the  direc- 
tion of  c,  to  the  lower  angle  of  the  incision, 
and  snipped  off.  The  upper  portion  is  then 
to  be  drawn  in  the  direction  of  d,  and  also 
divided.  There  is,  however,  this  disadvan- 
tage in  this  mode  of  operating  that,  if  there 
is  much  hfemorrhage,  the  upper  portion  of 
iris  is  somewhat  hidden,  or  it  may  slip  back 
into  the  anterior  chamber,  and  have  to  be 
searched  for. 

But  either  method,  if  well  accomplished, 
will  yield  an  excellent  artificial  pupil.  The 
iris  will  be  torn  away  quite  up  to  its  ciliary 
attachment,  and  the  pupil  will  consequently 
reach  quite  up  to  the  periphery  (Fig.  22). 

If  there  is  any  haemorrhage  into  the 
anterior  chamber,  the  blood  should  be  per- 
mitted to  escape  befoi^e  coagulation.  A 
small  curette  is  to  be  inserted  between  the 
lips  of  the  wound,  slight  pressure  being  at 


Fig.  21. 


Fig.  22. 


IRIDECTOMY.  177 

the  same  time  made  upon  the  eyeball  with  the  fixing  forceps,  so  as  to 
facilitate  the  escape  of  the  blood.  But  if  the  latter  does  not  escape 
readily,  it  should  not  be  forced  out  but  be  permitted  to  remain,  as  it 
will  soon  be  absorbed,  especially  if  a  compress  bandage  is  applied. 

I  have  described  the  mode  of  performing  iridectomy  in  the  outward 
direction,  as  this  is  the  easiest,  and  it  may  therefore  be  wise  for  a  per- 
fectly unskilled  operator  to  make  it  at  first  in  this  dii-ection,  until  he  has 
gained  a  certain  degree  of  practice  and  dexterity,  and  then  to  pass  over 
to  the  upward  or  inwai'd  incision.  The  operation  in  either  of  the  latter 
directions  is  certainly  more  difficult  than  the  temporal,  on  account  of 
the  prominence  of  the  nose  or  upper  edge  of  the  orbit,  and  the  con- 
sequent necessity  of  employing  a  knife  bent  at  a  more  or  less  acute 
angle,  which  an  unskilled  operator  may  find  somewhat  difficult  to  keep 
quite  flat. 

The  size  of  the  iridectomy  and  the  direction  in  which  it  is  to  be 
made,  should  vary  with  the  purpose  for  which  the  operation  is  performed. 
Thus,  if  it  be  done  solely  for  the  purpose  of  arresting  inflammation, 
or  of  diminishing  intra-ocular  tension,  it  should,  if  possible,  always  be 
made  directly  upwards,  for  then  the  upper  lid  will  cover  the  greater 
portion  of  the  artificial  pupil,  and  thus  not  only  hide  the  slight  defor- 
mity, but  also  cut  off"  much  of  the  irregularly  refracted  light.  In  these 
cases,  more  especially  in  glaucoma,  the  incision  should  be  made  some- 
what in  the  sclerotic,  so  that  the  iris  may  be  removed  quite  up  to  the 
ciliary  insertion,  and  should  be  of  a  sufficient  size  to  permit  of  the 
excision  of  about  one-fifth  of  the  ii'is.  We  find  that  if  both  these 
requirements  are  not  fulfilled,  the  beneficial  effect  of  the  iridectomy  in 
checking  the  inflammation  and  the  increase  in  the  tension  is  either 
greatly  diminished,  or  not  permanent. 

But  when  iridectomy  is  performed  simply  for  the  purpose  of  making 
an  artificial  pupil  through  which  to  admit  the  light,  as  in  opacity  of 
the  cornea,  lamellar  cataract,  etc.,  it  should  be  made  of  a  much  smaller 
size,  and,  if  possible,  inwards,  as  the  visual  line  cuts  the  cornea  slightly 
towai'ds  the  inner  side  of  the  centre.  But  with  regard  to  the  position, 
we  must  be  guided  by  the  condition  of  the  cornea,  endeavouring  to 
make  the  artificial  pupil  opposite  to  that  portion  of  the  cornea  which 
is  most  transparent,  and  most  true  in  its  curvature.  The  incision 
should  in  these  cases  be  slightly  in  the  cornea,  so  that  a  naiTow  belt  of 
iris  may  be  left  standing,  and  the  irregular  refraction  produced  by 
the  periphery  of  the  cornea  and  of  the  lens,  and  consequent  confusion 
of  sight,  be  diminished.  For  the  same  reason  the  iridectomy  should  not 
be  large,  otherwise  its  base  will  expose  a  considerable  portion  of  the 
edge  of  the  lens.  Hence  the  incision  should  be  made  with  a  narrow 
iridectomy  knife,  or  even  with  a  broad  needle.  If  a  very  small  incision 
is  made,  the  iiis  may  be  di-awn  out  with  a  blunt  silver  or  platinum  Lris 

N 


178  DISEASES   OF   THE   IRTS. 

hook,  instead  of  the  forceps,  just  as  in  the  operation  of  iridodesis.  Tliis 
mode  of  operating  is  also  indicated  in  those  cases  in  which  there  are 
extensive  adhesions  between  the  edge  of  the  pupil  and  the  anterior 
capsule.  In  such  cases  the  incision  should,  if  possible,  be  made  at  a 
spot  corresponding  to  a  point  at  which  the  edge  of  the  pupil  is  unad- 
herent,  so  that  the  hook  may  seize  this  portion  of  the  iris.  If  the  whole 
edge  of  the  pupil  is  adherent,  and  the  iris  is  thin  and  rotten,  it  is  often 
impossible  to  obtain  a  good  sized  pupil,  for  the  iris  breaks  down,  and 
tears  between  the  forceps,  and  only  small  portions  can  be  removed 
piece-meal.  Or  again,  the  adhesions  of  the  pupil  to  the  capsule  may  be 
so  firm,  that  they  resist  the  traction  of  the  forceps,  and  this  portion  of 
the  iris  remains  standing.  In  fact  we  have  performed  the  operation, 
which  Desmarres  has  recommended  in  such  cases,  and  has  termed  irido- 
rhexis.  A  portion  of  the  iris  is  excised,  leaving  the  adherent  pupillary 
edge  standing. 

(2.)  IRIDODESIS. 

This  valuable  and  ingenious  operation  was  devised  by  Mr.  Critchett,* 
and  is  very  useful  in  all  cases  in  which  we  desire  to  obtain  an  artificial 
pupil  for  optical  purposes  only,  as,  for  instance,  in  cases  of  opacity  or 
conicity  of  the  cornea,  or  of  lamellar  cataract,  etc. 

The  operation  is  to  be  performed  in  the  following  manner : — The 
patient  having  been  placed  under  the  influence  of  chloroform,  and  the 
eyelids  kept  apart  with  the  stop  speculum,  the  operator  fixes  the  eye- 
ball with  a  pair  of  forceps,  and  makes  an  incision  with  a  broad  needle 
in  the  sclero-corneal  junction,  slightly  encroaching  upon  the  cornea. 
If  the  incision  is  made  inwards  (which  is  the  best  direction)  and  the 
nose  is  prominent,  Mr.  Critchett  employs  a  broad  needle  bent  at  an 
angle  on  the  flat.  With  regard  to  the  size  of  the  incision,  it  is  of  import- 
ance to  remember  that  whilst,  on  the  one  hand,  it  should  be  sufiiciently 
large  to  admit  of  the  easy  introduction  of  the  hook  or  forceps,  it  must  not, 
on  the  other,  be  too  wide,  otherwise  the  strangulated  portion  of  the  iris, 
with  the  ligature,  may  be  drawn  into  the  anterior  chamber  when  the 
aqueous  humour  re-accumulates.  The  incision  having  been  completed, 
and  the  broad  needle  removed,  a  small  loop  of  very  fine  black  silk  is  to 
be  placed  directly  over  the  wound.  A  blunt  platinum  or  silver  hook 
(bent  at  the  requisite  angle)  is  then  to  be  introduced  through  the  loop 
into  the  anterior  chamber  to  the  proximate  edge  of  the  pupil,  which  is 
to  be  caught  up  by  it,  and  then  the  portion  of  iris  tints  secured  is  to  be 
carefully  and  gently  drawn  forth  into  the  loop.  If  it  is  desired  to  stretch 
the  opposite  portion  of  the  iris,  so  as  to  bring  it  opposite  an  opacity 

*  "R.  L.  O.  n.  Rep.,"  i,  220. 


IRIDODESIS.  179 

in  the  cornea  or  lens,  and  thus  to  displace  the  pnpil  considerably  to  the 
side  of  the  incision,  the  operator  must  be  extremely  careful  that,  whilst 
drawing  fortli  the  ii"is,  he  does  not  cause  a  separation  of  tbe  opposite 
border  from  its  ciliary  attachment  (coredialysis),  which  may  be  easily 
done  if  the  iris  be  put  too  much  upon  the  stretch,  or  drawn  forth  some- 
what roughly.  As  soon  as  a  sufficient  portion  of  iris  lies  within  the 
loop,  an  assistant,  with,  a  pair  of  broad  cilia  forceps  in  each  hand,  seizes 
the  two  free  ends  of  the  loop  and  ties  this  tightly,  so  as  to  include  the 
prolapsed  iris  firmly  within  it.  In  tightening  the  ligature,  he  should  not 
di'aw  the  ends  of  the  loop  away  from  the  eye,  but  should  follow  the  cur- 
vature of  the  sclerotic.  The  ends  of  the  ligature  are  then  to  be  cut  off", 
the  one  being  left  somewhat  longer  than  the  other,  in  order  that  it  may 
be  readily  seized  with  the  forceps,  if  the  loop  should  show  a  tendency  to 
be  drawn  into  the  anterior  chamber.  The  little  strangulated  portion  of 
iris  quickly  slmnks,  and  the  loop  may  be  removed  on  the  second  or  third 
day.  But,  instead  of  the  hook,  the  canula  forceps  may  be  employed, 
the  iris  being  seized  by  them,  about  midway  between  the  edge  of 
the  pupil  and  its  cihary  attachment.  The  hook  is,  however,  to  be  pre- 
fen*ed. 

I  have  above  described  the  operation  which  is  to  be  performed  when 
the  artificial  pupil  is  to  extend  to  the  periphery.  But  if  we  desire 
simply  to  displace  and  enlarge  the  original  pupil  from  its  central 
position  towards  one  side,  preserving  at  the  same  time  the  constrictor 
pupillse  intact,  the  peripheral  portion  of  the  iris  must  be  seized  with  the 
canula  forceps,  and  drawn  forth  through  the  loop  until  the  pupil  occu- 
pies the  desired  position,  when  the  ligature  is  to  be  tightened. 

It  may  occasionally  occur  that,  although  the  sight  is  considerably 
improved  by  the  iridodesis,  the  patient  greatly  feels  the  want  of  more 
light,  and  a  stronger  ilkimination  of  the  retinal  image.  In  such  cases 
!Mr.  Critchett  has  succeeded  admirably,  by  making  a  second  iridodesis 
in  the  same  eye,  in  such  a  manner  as  to  enlarge  the  pupil  and  alter  its 
shape,  giviug  it  a  somewhat  crescentic  form,  with  the  two  corners  of  the 
crescent  cut  off. 

The  operation  of  iridodesis  is,  as  a  rule,  quite  free  from  danger,  and 
productive  of  but  very  little  irritation.  In  very  rare  instances  it  may, 
however,  give  rise  to  iritis,  or  even  suppurative  irido-cyclitis.  Such  cases 
have  been  recorded  by  Alfred  Graefe,*  Steffan,t  etc.,  but  although  I 
have  a  large  experience  of  the  operation,  both  in  the  hands  of  others 
and  in  my  own,  I  have  never  met  with  a  single  case  ia  which  it  caused 
inflammatory  compHcations.  In  order  to  avoid  the  risk  of  irrita- 
tion, and  also  to  simplify  the  operation,  Wecker  has  suggested  that  the 
prolapse  of  the  iris,  instead  of  being  tied,  should  be  allowed  to  heal  in 

*  "  A.  f.  O.,"  ix,  3,  199.  t  Ibid.,  x,  1,  122. 

N    2 


180  DISEASES   OF   THE  IRIS. 

the  wound.  He  makes  the  incision  rather  farther  in  the  sclerotic,  so  as 
to  obtain  a  long  track  ;  he  then  seizes  the  iris  with  a  very  fine  pair  of 
iridectomy  forceps,  and  draws  it  out  into  the  incision.  To  raaintain  it 
in  this  position,  and  to  accelerate  the  healing  of  the  wound,  a  firm  com- 
press bandage  is  applied.  The  prolapse  becomes  firmly  adherent  in 
the  track  of  the  wound,  and  the  little  protruding  portion  soon  drops 
ofi". 


(3.)  ARTIFICIAL  PUPIL  MADE  BY  INCISION  OF  THE  IRIS. 

We  sometimes  find  after  a  perforating  wound  or  ulcer  of  the  cornea, 
or  the  common  flap  operation  for  cataract  with  extensive  prolapse,  that  the 
iris  presents  a  plane  surface  tightly  stretched  from  the  cicatrix  to  the 
periphery  of  the  cornea,  and  that  there  is  no  trace  of  a  pupU.  If  the 
lens  is  absent,  a  very  fair  artificial  pupil  may  often  be  obtained  in  these 
cases  by  simply  splitting  the  fibres  of  the  iris  across  with  a  broad 
needle.  The  edges  of  the  incision  will  generally  retract,  and  a  very  good 
sized  pupil  be  left ;  if  this  is  not  the  case  a  Tyrrel's  hook  may  be  passed 
through  the  corneal  incision,  and  one  edge  of  the  incised  portion  of  iris 
be  caught,  drawn  forth,  and  excised. 


(4.)     CORELYSIS. 

The  detachment  of  adhesions  between  the  edge  of  the  pupil  and  the 
anterior  capsule  of  the  lens  by  operative  interference,  was  first  exten- 
sively practised  by  Mr.  Streatfeild,*  and  subsequently  also  by  Weber.f 
The  patient  having  been  chloroformed,  and  the  lids  fixed  with  the  stop 
speculum,  an  incision  is  to  be  made  in  the  cornea  with  a  broad 
needle,  of  sufficient  size  readily  to  admit  the  spatula  hook  into  the 
anterior  chamber.  Prior  to  the  operation,  a  strong  solution  of  atropine 
should  be  applied  to  the  eye,  so  that  any  unadherent  portions  of  the 
pupil  may  become  dilated.  The  exact  position  and  size  of  the  different 
posterior  synechiaB  should  then  be  carefully  ascertained  with  the  oblique 
illumination,  for  upon  their  position  and  number  raust  depend  the  situa- 
tion of  the  incision,  and  with  regard  to  the  latter  it  should  be  remem- 
bered that  no  adhesion,  directly  behind  the  incision  through  which  the 
spatula  hook  has  to  be  introduced,  can  be  torn  through.  It  is  best, 
therefore,  to  make  the  incision  at  a  point  situated  sideways  to  the  prin- 
cipal adhesions  ;  thus  if  there  are  two  adhesions  opposite  to  each  other, 
the  incisions  should  be  made  between  them  so  that  by  a  simple  half 

*  "  R.  L.  O.  11.  Hop.,"  i,  6,  and  ii,  309. 
t  "A.  f.  O.,"  vii,  1,  aud  viii,  1,  p.  35i. 


IRIDODIALYSIS.  181 

rotation  of  the  spatula  each  may  be  easily  torn  tlirougli.  If  there  are 
several  adhesions  and  one  broad  unattached  portion  of  the  pupil,  the 
incision  should  be  made  opposite  the  latter.  Mr.  Streatfeild  recommends 
that  the  broad  needle  should  be  rapidly  withdrawn  from  the  anterior 
chamber,  so  as  to  allow  as  little  of  the  aqueous  humour  to  escape  as 
possible.  Whereas  Weber  prefers  to  withtb^aw  the  instrument  very 
slowly  so  as  to  permit  the  gradual  escape  of  the  aqueous  humour,  in 
order  that  the  crystalline  lens  may  come  in  contact  with  the  cornea  and 
thus  be  steadied  ;  the  spatula  will  glide  over  the  former,  and  there  is  less 
chance  of  injuring  the  capsule. 

The  incision  having  been  finished,  a  small  spatula  hook  (Fig.  23)  is 
introduced  into  the  anterior  chamber,  and,  with  a  somewhat 
lateral  "wriggling"  movement,  the  instrument  is  passed  Fig-  23. 
slightly  beneath  the  iris,  at  a  point  free  of  adhesions,  and  is 
then  passed  behind  the  nearest  adhesion,  and  drawn  gently 
and  slowly  towards  the  operator  so  that  it  breaks  down  the 
band  before  it,  care  being  taken  to  keep  it  quite  parallel  to 
the  iris  lest  the  capsule  of  the  lens  should  be  injui^ed.  The 
adhesion  may  yield  at  once  before  the  pressure  of  the  spatula, 
but  if  it  resists  it  may  be  caught  in  the  hook  and  thus  torn 
through. 

(5.)     IRIDODIALYSIS. 

If  nearly  the  whole  cornea  is  opaque,  and  there  is  only  a  narrow 
transparent  rim  left,  it  may  be  advisable  to  adopt  this  mode  of  forming 
an  artificial  pupil,  for  if  the  incision  is  made,  as  in  iridectomy,  in  the 
sclero-comeal  junction,  it  is  sometimes  followed  by  some  opacity  of  the 
cornea  close  to  the  incision,  and  this  would  prove  very  disadvantageous 
where  the  rim  of  clear  cornea  is  but  very  narrow.  An  incision  is  made  in 
the  cornea  with  a  broad  needle,  at  a  sufficient  distance  from  the  point 
where  the  iris  is  to  be  removed  from  its  ciHary  attachment,  for  the 
forceps  or  hook  to  be  easily  managed.  A  fine  pair  of  iridectomy  (or 
canula)  forceps  are  passed  into  the  anterior  chamber,  a  fold  of  iris 
seized,  gently  torn  from  its  insertion,  and  a  portion  drawn  forth  through 
the  incision  and  snipped  off.  In  this  way  a  fair  sized,  marginal  pupil 
can  be  made  opposite  the  transparent  edge  of  the  cornea.  Even  if  the 
vicinity  of  the  incision  should  become  a  little  clouded,  this  will  be  at  the 
same  distance  from  the  new  pupil. 

I  must  now  briefly  enumerate  the  difierent  diseases  in  which  an  iri- 
dectomy is  indicated.  These  may  be  divided  into  two  groups,  viz. : — 
those  affections  in  which  the  operation  is  performed  for  the  purpose  of 
diminishing  inflammatory  symptoms  and  an  increase  in  the  eye-tension, 
and  those  in  which  the  object  is  simply  to  make  an  artificial  pupU. 


182  DISEASES  OF   THE  IRIS. 

In  the  first  group  it  is  indicated — 1.  In  ulcers  of  the  cornea 
which  threaten  extensive  perforation,  or  cases  of  suppurative  comeitis. 
The  iridectomy  diminishes  the  intra-ocular  tension,  and  thus  affords  a 
favourable  opportunity  for  the  process  of  reparation,  and  also  improves 
the  nutrition  of  the  parts.  2.  If  the  cornea,  after  perforation,  shows  a 
tendency  to  become  prominent  and  staphylomatous  at  this  point,  and 
more  especially  if  there  is  any  increase  in  the  intra-ocular  tension. 
3.  In  obstinate  fistula  of  the  cornea,  and  in  prolapse  of  the  iris.  4.  In 
recurrent  or  chronic  iritis  and  irido-choroiditis,  pai'ticularly  if  the  com- 
miinication  between  the  anterior  and  posterior  chambers  is  interrupted 
by  circular  synechia.  Also  in  cases  in  which  a  foreign  body  has  be- 
come lodged  in  the  iris,  or  a  tumour  or  cyst  exist  in  the  latter.  5.  In 
traumatic  cataract,  accompanied  by  much  swelling  of  the  lens  substance, 
great  irritation  of  the  eye,  and  augmented  tension.  Also  in  various 
operations  for  cataract,  the  object  being  partly  to  prevent  bruising  of 
the  iris  during  the  extraction  of  the  lens,  and  partly  to  diminish  the 
tendency  to  subsequent  inflammatory  comphcations.  6.  In  the  exten- 
sive group  of  glaucomatous  diseases,  in  which  there  is  increase  of  the 
intra-ocular  tension,  leading  finally  to  excavation  of  the  optic  nerve  and 
blindness.  The  importance  of  an  early  operation  in  such  cases  cannot 
be  over-estimated. 

In  the  second  class  of  cases  in  which  the  object  of  the  iridectomy  is 
simply  to  afibrd  an  artificial  pupil,  it  is  indicated  in  the  following  afiec- 
tions : — 1.  In  opacities  of  the  cornea,  also  in  conical  cornea.  In  the 
latter  case  the  object  of  the  operation  is,  however,  strictly  speaking,  two- 
fold, viz. :  to  diminish  the  intra-ocular  tension,  and  also  to  make  a 
pupil  opposite  a  portion  of  the  cornea  whose  curvature  is  but  slightly,  if 
at  all,  altered.  2.  In  occlusion  of  the  pupil  after  iritis.  3.  In  lamellar 
cataract,  and  in  dislocations  of  the  lens. 


9.— CHAIN^GES  IN  THE  FORM  AND  CONTENTS  OF  THE 
ANTERIOR  CHAMBER. 

•  The  size  of  the  anterior  chamber  may  undergo  considerable  altera- 
tion. Thus,  if  the  intra-ocular  tension  be  much  augmented,  or  the  iris 
is  bulged  forward  by  a  collection  of  fluid,  or  by  exudation- masses 
between  the  posterior  surface  of  the  iris  and  the  capsule  of  the  lens, 
the  anterior  chamber  may  be  extremely  shallow,  the  iiis  being  perhaps 
almost  in  contact  with  the  posterior  surface  of  the  cornea.  Whereas, 
when  the  anterior  portion  of  the  eyeball  is  distended  and  enlarged 
(hydrophthalmos),  or  when  the  crystalline  lens  is  absent  or  displaced, 
the  anterior  chamber  increases  in  depth.  The  size  of  the  latter  also 
varies  according  to  the  a,ge,  and  the  state  of  refraction.    It  diminishes  with 


CHANGES  IN  THE  FORM,  ETC.,  OF   THE  ANTERIOR  CHAMBER.    183 

advancing  years,  and  is  deeper  in  myopic  and  more  sliallow  in  hyper- 
metropic persons. 

Eflfusions  of  lymph  and  pus  may  take  place  into  the  anterior 
chamber  and  sink  down  to  the  bottom  in  the  form  of  hypopyon,  which 
may  attain  a  considerable  size,  and  even  fill  the  whole  of  the  anterior 
chamber.  The  lymph  or  pus  may  be  effused  either  from  the  cornea,  the 
iris,  or  the  ciliary  body,  as  has  been  described  at  length  in  the  articles 
upon  the  diseases  of  these  parts. 

Blood  may  also  be  effused  into  the  anterior  chamber,  this  condition 
being  termed  "  hypsemia."  The  hgemorrhage  may  be  either  spontaneous 
or  traumatic  in  its  origin.  In  the  latter  case,  it  may  be  due  to  a  wound 
of  the  cornea,  iris,  ciliary  body,  etc.,  or  it  may  be  produced  by  a  simple 
blDw  or  fall  upon  the  eye  (as  from  a  cricket  or  racket  ball,  a  "  cat,"  or 
a  blow  from  the  fist),  without  any  rupture  of  the  external  coats  of  the 
eye.  The  anterior  chamber  is  tilled  with  blood,  and  when  this  has 
become  partially  absorbed  we  find  perhaps  that  the  lens  has  been  dis- 
located, and  that  there  is  also  haemorrhage  into  the  vitreous  humour. 
Spontaneous  hypsemia  is  of  rare  occurrence.  It  has  been  known  to 
occur  periodically  during  the  time  of  menstruation,  perhaps  vicariously, 
or  after  the  catamenia  had  ceased.  Cases  have  been  recorded  in 
which  the  patient  could  voluntarily  produce  an  effusion  of  blood  into 
the  anterior  chamber  by  stooping  or  rapidly  shaking  his  head.*  The 
best  ti'eatment  is  the  application  of  a  firm  compress  bandage  to  the 
eye,  for  this  accelerates  the  absorption  of  the  blood  more  than  any  other 
remedy.  If  there  is  much  irritability  of  the  eye  or  any  iritis,  atropine 
di'ops  should  be  frequently  applied. 

Foreign  bodies,  such  as  portions  of  metal,  gun  cap,  splinters  of 
glass,  eyelashes,  etc.,  may  penetrate  the  cornea  and  become  lodged  in  the 
anterior  chamber,  lying  either  free  in  it,  or  being  perhaps  partly  adherent 
to  the  cornea  or  the  iris,  and  partly  situated  in  the  anterior  chamber. 
Their  presence  in  the  latter  frequently  sets  up  severe  iritis  or  irido- 
choroiditis.  But  in  other  cases,  after  the  immediate  effects  of  the  injury 
have  passed  away,  the  foreign  body  may  remain  for  many  years  inno- 
ciious  in  the  anterior  chamber,  without  either  provoking  any  serious 
injury  to  the  affected  eye  or  symptoms  of  sympathetic  disease  in  the 
other.  Thus  Samischf  records  a  case  in  which  a  fragment  of  stone 
remained  twelve  years  in  the  anterior  chamber  without  exciting  any 
serious  injury.  The  foreign  body  had  originally  become  lodged  in  the 
lens,  the  latter  became  absorbed,  and  then  the  fragment  of  stone  fell 
into  the  anterior  chamber,  remaining  attached  to  the  secondary  cataract 
by  a  fine  filament.     As  it  had  set  up  some  irritation  a  fortnight  before 

*  For  cases  of  this  kind,  vide  "  A.  f.   O.,"   vii,  1,  65  ;  Wallter,  "  System  der 
Chirurgie,"  1848  ;  also  Mooren,  op.  cit. 
+  "  Klin.  Monatsblatter,"  III,  46. 


184  DISEASES   OF   THE  IRIS. 

the  patient  consulted  Samisch,  the  latter  extracted  it  successfully  by 
a  large  linear  incision  in  the  cornea  combined  with  an  iridectomy. 
Wecker*  extracted  with  success  a  fragment  of  stone  which  had  re- 
mained fourteen  years  in  the  anterior  chamber,  without  causing  any 
irritation. 

In  removing  these  foreign  bodies  from  the  anterior  chamber,  care 
must  be  taken  that  the  incision  in  the  cornea  is  of  a  sufficient  size, 
and  so  situated,  that  the  foreign  body  can  be  easily  reached ;  a  large 
iridectomy  should  then  be  made,  and  the  foreign  body  seized  with  the 
iridectomy  forceps  or  an  iris  hook,  and  extracted.  If  the  foreign  body 
{e.g.,  a  splinter  of  steel)  is  partly  in  the  cornea  and  partly  in  the 
anterior  chamber,  the  blade  of  the  iridectomy  knife  or  of  the  broad  needle 
should  be  passed  behind  it,  so  as  to  steady  it  and  push  it  forward 
through  the  cornea,  where  its  anterior  extremity  should  be  seized  with 
a  pair  of  forceps  and  extracted. 

Cysticerci  are  sometimes  met  with  in  the  anterior  chamber,  and 
about  twenty  cases  of  this  kind  have  been  recorded  by  different  authors. 
The  diagnosis  is  not  difl&cult,  for  the  Httle  animal  is  noticed  in  the  form 
of  a  small  transparent  vesicle,  generally  lying  upon  the  surface  of  the 
iris.  The  vesicle  shows  at  times  very  decided  movements,  more 
especially  when  the  pupil  is  stimulated  to  active  contraction  by  'the 
action  of  strong  light,  the  head  and  neck  of  the  animal  being  perhaps 
stretched  out  and  moved  about.  The  cysticercus  may  either  lie  free  in 
the  anterior  chamber,  or  be  partly  adherent  to  the  iris  or  cornea.  The 
following  case  of  Mr.  Pridgin  Teale'sf  illustrates  admirably  the  symp- 
toms presented  by  the  presence  of  a  cysticercus  and  the  mode  of 
treatment  to  be  adopted : — "  Mary  Isabel  Bateman,  set.  10,  living  at 
Anerley,  was  brought  to  me  on  June  2nd,  in  consequence  of  tenderness 
of  the  right  eye.     On  examining  the  eye  there  was  seen  (vide  Fig.  24) 

on  the  surface  of  the  lower  part  of  the  iris 
an  opaque  body,  constricted  in  the  middle, 
and  rather  longer  than  an  hemp  seed,  which 
was  evidently  causing  some  distress  to  the 
eye.  The  conjunctiva  was  sHghtly  injected, 
the  cornea  was  bright,  but  dotted  on  its 
posterior  surface  with  minute  spots,  as  in 
corneo-iritis ;  the  iris  was  active,  except  at 
the  situations  of  the  white  body,  near  which 
it  was  adherent  to  the  capsule  of  the  lens. 
Tension  normal.  Reading  No.  16  Jager." 
The  mother  stated  that  for  two  or  three  years  the  eye  had  been  occasion- 
ally inflamed.    Six  weeks  ago  she  first  noticed  a  speck  on  the  iris,  about 

*  "  Klin.  Monatsbl.,"  1867,  36. 
t  "  R.  L.  O.  H.  Rep.,"  V,  320. 


IRIDO-CHOROIDITIS. 


185 


the  size  of  a  piu's  head,  whicii  became  doubled  in  size  at  the  end  of 
five  weeks.  The  child  had  always  been  delicate,  and  had  long  suffered 
from  thread- worms,  but  never  from  tape- worm.  On  June  9th  Mr.  Teale 
made  an  incision  at  the  margin  of  the  cornea  with  a  cataract  knife  and 
withdrew  the  piece  of  iris 
on  which  the  animal  was 
fixed,  and  cut  it  off  without 
destroying  the  cysticercus. 
When  removed  from  the 
eye  the  slow  movements  of 
the  body  and  changes  of 
shape  were  easily  detected. 
On  examination  with  the 
microscope,  the  head  and 
neck,  surmounted  by  the 
circle  of  booklets  and  foui' 
suckers,  were  seen  to  pro- 
ject from  the  side  of  the 
body  (vide  Fig.  25). 

The  removal  of  the  cys- 
ticercus was  soon  followed 

by  the  Jasappearance  of  all  symptoms  of  inflammation  and  irritability 
of  the  eye,  and  four  months  afterwards  the  patient  was  able  to  read 
Jiiger  No.  1. 

10.— IRIDO-CHOROIDITIS. 

I  have  already  pointed  out,  when  speaking  of  iritis,  that  on  account 
of  the  close  relationship  between  the  iris,  ciliary  body,  and  the  choroid 
(which  in  truth  form  one  continuous  tissue,  the  uveal  tract),  any  in- 
flammation commencing  in  the  iris  is  very  prone  to  extend  to  the  ciliary 
body  and  choroid,  or  vice  versa.  The  most  frequent  cause  of  such  an  exten- 
sion of  the  inflammation  of  the  iris  to  the  choroid  is  to  be  sought  in  the 
presence  of  considerable  posterior  synechioe,  or  still  more  in  complete 
exclusion  of  the  pupil.*  In  such  cases,  the  recurrence  of  the  inflam- 
mation, and  its  extension  to  the  ciKary  body  and  choroid  are  partly  due 
to  the  constant  irritation  and  teasing  kept  up  by  the  adhesions  at  the 


*  I  must  remind  the  reader  that  by  this  term  "  exchision  of  the  pupil "  ia 
meant,  that  the  adhesion  between  the  edge  of  the  pupil  and  the  capsule  of  the  lens 
extends  completely  round  the  circumference  of  the  pupil,  and  thus  shuts  off  the 
communication  between  the  anterior  and  posterior  chamber.  The  area  of  the  pupil 
may,  in  such  a  case,  be  perfectly  clear  and  unoccupied  by  lymph.  If  this  is  not  the 
case,  but  it  is  filled  with  a  depositor  plug  of  lymph,  it  is  termed  "occlusion"  of 
the  pupil,  and  this  involves  also  exclusion. 


186  DISEASES   OF   THE  IRIS. 

edge  of  the  pnpil,  preventing  tlie  normal  dilatations  and  contractions 
of  the  pupil,  which  take  place  in  accordance  with  any  alteration  in  the 
degree  of  illumination,  the  movements  of  the  eye,  and  the  changes  in 
the  accommodation.  But  they  are  still  more  caused  by  the  interruption 
in  the  communication  between  the  anterior  and  posterior  chamber  (in 
cases  of  exclusion  of  the  pupil),  which  prevents  that  regulation  and  just 
balance  of  the  intra- ocular  tension  in  front  and  behind  the  iris,  which 
always  exists  in  the  healthy  eye.  Thus,  if  there  is  any  increase  in  the 
vitreous  humour,  the  anterior  chamber  becomes  narrower,  and  contains 
less  aqueous  humour;  if,  on  the  other  hand,  the  quantity  of  the  aqueous 
humour  is  increased,  the  iris  is  somewhat  cujDped  backwards,  and  the 
fluid  in  the  posterior  chamber  diminished  in  quantity.  In  this  way, 
changes  in  the  amount  of  the  fluids  in  different  parts  of  the  eye  are  pre- 
vented from  exercising  any  deletei'ious  influence,  if  their  augmentation 
does  not  exceed  a  certain  degree.  For  on  account  of  the  regulation 
between  the  anterior  and  posterior  chamber  no  harra  accrues.  But  it 
is  quite  different  when  this  communication  is  stopped,  and  the  iris  forms, 
so  to  say,  a  firm  barrier  between  the  anterior  and  posterior  chamber. 
If  there  is  any  increase  of  tension  in  the  posterior  portion  of  the 
eye,  it  cannot  be  relieved  at  the  expense  of  fluid  in  the  anterior 
chamber,  consequently  a  stasis  occurs  in  the  circulation  of  the  inner 
tunics  of  the  eyeball,  soon  followed  by  inflammatory  compHcations  of  a 
serious  nature. 

In  practice  we  can  distinguish  two  principal  forms  of  irido-choroi- 
ditis,  presenting  certain  characteristic  differences,  which  it  is  of  con- 
sequence to  observe,  not  only  with  regard  to  the  prognosis,  but  also  with 
regard  to  the  line  of  operative  treatment  which  is  required  in  each. 

In  the  first  form  the  disease  commences  with  iritis,  and  if  the  pupil 
is  not  kept  widely  dilated  with  atropine,  posterior  synechise  soon  form 
and  rapidly  lead  to  exclusion  of  the  pupil  from  circular  synechia. 
The  pupil  may  remain  clear  excepting  just  at  its  edge,  where  it  shows 
a  well  marked  border  of  pigmented  exudation.  Gradually  we  notice 
that  small  knob- like  bulgings  show  themselves  in  the  iris,  which  may 
remain  chiefly  confined  to  one  portion,  or  extend  more  or  less  to  the 
whole  of  it,  so  that  the  iris  is  bulged  forward  into  numerous  pro- 
minences, like  sails  before  the  wind.  This  bulging  is  not  due  to  any 
firm  exudation  on  the  posterior  surface  of  the  iris,  but  to  a  serous 
effusion  behind  it ;  and  the  partial  bulging  is  due  to  the  fact  that  some 
portions  of  the  iris  resist  the  pressure  of  the  fluid  more  than  others. 
The  appearance  presented  by  such  cases  is  very  peculiar  and  cha- 
racteristic. 

On  account  of  the  firm  adhesion  of  the  whole  circumference  of  the 
pupil  to  the  capsule,  the  iris  cannot  at  this  point  yield  to  the  pressure 


IRIDO-CHOROmiTIS.  187 

of  the  fluid  behind  it,  but  bulges  out  between  the  pupil  and  its  ciliary 
adhesion  into  more  or  less  numerous,  knob-like  protuberances,  which 
are  sometimes  so  considerable  in  size,  as  to  come  in  contact  here  and 
there  with  the  posterior  sui-face  of  the  cornea.  The  bulge  slopes  gradu- 
ally down  towards  the  circumference  of  the  cornea,  but  passes  steeply 
down  to  the  pupil,  which  lies  in  a  crater-like  depression. 

The  iris  is  generally  very  much  discoloured,  and  of  a  grey  ash- 
like, or  greenish  tint.  On  closer  examination,  more  especially  with  the 
oblique  illumination,  it  will  be  seen  that  its  fibrillee  are  somewhat 
opened  up  and  stretched  apart,  and  that  it  is  traversed  by  a  few  dilated 
tortuous  veins. 

The  tension  of  the  eye  is  generally  at  first  normal,  but  may  then 
become  considerably  increased,  finaEy  however  it  diminishes  more  and 
more  as  the  eye  becomes  atrophied.  If  the  pupil  is  clear,  the  sight  may 
at  the  outset  be  good,  but  when  the  bulging  of  the  iris  occurs,  it 
rapidly  deteriorates.  If  the  refi-active  media  and  the  pupil  are  suffi- 
ciently clear  to  permit  of  an  ophthalmoscopic  examination,  the  vitreous 
humour  is  often  seen  to  be  diffusely  clouded,  with  delicate,  floating,  or 
fixed  opacities  suspended  in  it,  proving  that  the  disease  is  no  longer 
confined  to  the  iris,  but  has  extended  to  the  ciliary  body  and  choroid. 
If  an  iridectomy  is  made  in  such  a  case,  we  notice  that  when  the  knife 
is  withdrawn,  some  aqueous  humour  escapes  from  the  anterior  chamber ; 
but  that  the  latter  is  not  emptied  completely,  in  consequence  of  the 
intraocular  pressure  not  being  able  to  affect  the  anterior  chamber  on 
account  of  the  exclusion  of  the  pupil.  A  sufficiently  large  piece  of  iris 
can  generally  be  seized  with  the  forceps  and  excised,  a  copious  stream  of 
watery  yellow  fluid  simultaneously  escaping  from  behind  it.  The  iris 
now  at  once  recedes  to  its  normal  plane,  even  although,  as  Von  Graefe 
points  out,  the  bulging  part  itself  has  not  been  excised,  but  only  a 
neighbouring  portion  of  iris.  The  artificial  pupil  thus  obtained,  may  be 
almost  entirely  clear,  excepting  jiist  at  the  edge  of  the  pupil ;  or,  as  fre- 
quently occurs,  a  more  or  less  considerable  portion  of  the  uvea  is  found 
to  be  left  behind  in  it ;  the  uvea  having  been  separated  from  the  iris 
proper  by  the  fluid,  and  become  attached  to  the  capsule  of  the  lens. 

The  second  form  of  irido- choroiditis  presents  very  different  appear- 
ances. The  iris  instead  of  being  arched  forward  in  Httle  knob-like 
projections,  is  perfectly  straight  and  even  on  its  surface,  although  it  is 
pressed  forward  towards  the  cornea,  producing  great  shallowness  of 
the  anterior  chamber,  but  the  pupil  is  not  drawn  back.  There  is  com- 
plete exclusion  of  the  pupil,  and  its  area  is  generally  occupied  by  a 
more  or  less  dense  false  membrane,  or  by  a  thick  plug  of  lymph.  The 
tissue  of  the  iris  looks  stretched,  its  fibrillse  are  indistinct,  its  surface 
discoloured,  and  of  a  dirty  reddish  tint,  which  is  partly  due  to  the 
cloudiness  of  the  aqueous  humour,  but  chiefly  to  the  numerous  large 


188  DISEASES   OP   THE  IRIS. 

tortuous  blood-vessels  whicli  traverse  its  surface;  there  being  a 
considerable  stasis  in  the  venous  circulation  and  mecLanical  liyperaemia, 
on  account  of  the  inflammatory  affection  of  the  ciliary  body  and  choroid. 
The  pressing  forward  of  the  iris  is  not  due  to  a  collection  of  fluid 
behind  it,  but  to  the  pushing  forward  of  the  lens  (with  whose  capsule  the 
iris  is  intimately  connected  by  means  of  extensive,  thick  masses  of  exuda- 
tion), which  yields  to  the  intra-ocular  pressure.  The  false  membrane 
behind  the  iris  is  generally  very  considerable,  consisting  of  a  thick, 
organized,  felt-like  mass  of  exudation,  which  adheres  closely  to  the 
capsule  of  the  lens,  and  perhaps  fills  up  a  great  portion  of  the  posterior 
chamber.  The  intra- capsular  cells  generally  proliferate,  and  become 
clouded,  but  the  lens  itself  often  remains  transparent. 

In  these  cases,  the  simple  iridectomy  is  of  no  avail,  for  even  if  we 
can  remove  a  portion  of  the  iris  (whicli  is  often  very  difiicult),  the 
opening  thus  made  is  again  rapidly  closed  by  exudation,  for  the 
operation  excites  a  fresh  attack  of  inflammation,  and  finally  such  eyes 
will  undergo  gradual  destruction  from  atrophy,  if  they  are  not  operated 
upon  in  the  manner  described  below. 

I  must  state  that  the  distinctive  characters  of  these  two  forms  of 
irido-choroiditis  are  not  always  so  strongly  marked,  for  we  often  meet 
with  mixed  forms ;  or,  again,  the  second  may  supervene  upon  the  first, 
forming,  so  to  say,  a  more  advanced  and  hopeless  stage. 

It  has  been  stated  above,  that  irido-choroiditis  may  ensue  upon  an 
inflammation  which  primarily  afiected  the  iris  and  then  extended  to  the 
ciliary  body  and  choroid  ;  or  that  it  may  begin  in  the  latter  and  only 
subsequently  attack  the  iris.  It  is  sometimes  difficult,  at  a  late  stage 
of  the  disease,  to  ascertain  with  anything  like  certainty,  which  course 
the  disease  had  originally  pursued.  The  following  facts  will,  however, 
afford  us  some  guidance.  When  the  disease  originated  in  the  iris,  we  find 
that  there  were  well  marked  symptoms  of  recurrent  inflammation,  and 
that  the  structure  of  the  iris  is  considerably  changed,  being  much  dis- 
coloured, thinned  and  atrophied.  The  lens  also  becomes  less  frequently 
opaque,  and  only  at  a  much  later  period.  The  dimness  of  sight  is  also 
less  considerable,  and  depends  at  first  chiefly  upon  the  deposit  of  lymph 
in  the  pupil,  and  only  subsequently  upon  the  cloudiness  of  the  lens  or 
vitreous  humour.  Whereas,  if  the  inflammation  commenced  in  the 
choroid,  the  train  of  symptoms  is  different.  There  are  marked 
symptoms  of  choroiditis,  with  opacity  of  the  vitreous  humour,  followed 
very  generally  by  detachment  of  the  retina  from  a  serous  or  htemorr- 
hagic  efi'usion.  The  tension  of  the  eyeball  diminishes.  Then  an 
opacity  of  the  lens  supervenes,  very  frequently  commencing  at  its 
posterior  pole,  and  gradually  extending  thence  to  the  whole  lens  sub- 
stance. At  a  later  stage,  the  lens  undergoes  further  degenerative 
changes,  becoming  chalky,  and  transformed  into  a  "  cataracta  accreta." 


IRIDO-CHOROIDITIS.  189 

The  iris  may  either  remain  unaffected  until  a  late  period  in  the  disease, 
and  not  until  some  time  after  the  formation  of  cataract,  or  it  may  become 
inflamed  at  an  earlier  stage ;  but  the  iritis  is  generally  insidious, 
and  not  accompanied  by  any  marked  inflammatory  symptoms.  The 
pupil  becomes  adherent,  lymph  is  effused  in  its  area  and  on  the  posterior 
surface  of  the  iris,  which  may  become  bulged  forward  by  fluid,  or  pressed 
forward  by  dense  masses  of  exudation.  One  very  important  guide  by 
which  to  distinguish  between  this  form  of  irido- choroiditis  and  that 
commencing  \\ath  an  inflammation  in  the  iris,  is  the  degree  of  sight  and 
the  state  of  the  field  of  vision.  The  perception  of  light  will  be  far  less 
in  the  former  case,  and  there  will  be  a  marked  contraction  or  absence  of 
that  part  of  the  field  (the  upper)  which  corresponds  to  the  detached 
portion  of  the  retina.  Thus,  if  the  light  from  a  lamp  is  distinguished 
when  it  is  held  in  the  lower  half  of  the  field,  but  becomes  unap parent 
when  it  is  removed  into  the  upper  half,  it  indicates  a  detachment  of  the 
lower  portion  of  the  retina. 

The  sight  is  generally  very  much  impaired  in  cases  of  irido-choroiditis, 
so  that  the  patient  can  only  perhaps  distinguish  large  letters,  count 
fingers,  or  has  only  simple  perception  of  light.  In  irido-choroiditis 
uncomplicated  by  detachment  of  the  retina,  or  glaucomatous  or  atrophic 
changes  in  the  retina  and  optic  nerve,  the  quantitative  field  of  vision 
should  be  good. 

The  prognosis  is,  of  course,  very  variable,  according  to  the  stage 
and  form  of  the  disease.  If  a  case  of  irido-choroiditis  (uncomplicated 
with  extensive  lesions  of  the  choroid,  detachment  of  the  retina,  or 
opacity  of  the  lens)  be  seen  at  the  outset,  whilst  the  changes  in  the  iris 
are  still  but  slight,  the  area  of  the  pupil  clear,  or  only  occupied  by  a 
film  of  exudation,  and  there  are  no  masses  of  exudation  membranes  be- 
hind the  iris,  the  prognosis  may  be  favourable  if  the  sight  be  still 
tolerably  good,  and  the  field  of  vision  normal. 

The  first  form  of  irido-choroiditis,  in  which  the  iris  is  bulged  forward 
by  fluid,  affords  a  much  better  prognosis  than  the  second.  The  most 
hopeless  of  all,  are  of  course  the  cases  of  irido-choroiditis  with  detach- 
ment of  the  retina.  In  such  a  case,  or  if  there  is  no  perception  of  light 
left,  no  operation  should  be  attempted  excepting  for  the  sake  of  relieving 
pain,  or  diminishing  the  risk  of  sympathetic  ophthalmia.  A  certain 
degree  of  atrophy  of  the  eye  (if  it  be  not  too  far  advanced,  and  the 
perception  of  light  and  field  of  vision  are  good)  does  not  contra-indicate 
an  operation,  for  we  find  that  the  iridectomy  often  arrests  the  atrophy, 
and  that  the  eye  regains  its  plumpness,  and  a  normal  degree  of  tension. 

The  most  frequent  cause  of  irido-choroiditis  is  the  presence  of  pos- 
terior synechias,  above  all,  the  circular  form.  The  presence  of  adhesions 
between  the  edge  of  the  pupil  and  the  capsule  of  the  lens  lead  to  frequent 
recui'rences  of  the  uitis,  more  lymph  is  effused,  more  synechise  formed, 


190  DISEASES  OF  THE   IRIS. 

until  finally  the  pnpil  is  excluded,  and  then,  if  this  has  not  already 
occurred,  future  inflammations  are  sure  to  extend  from  the  iris  to  the 
ciliary  body  and  the  choroid.  The  best  safeguard  against  a  recurrence 
of  the  ii'itis  and  the  supervention  of  irido-choroiditis,  is  to  cure  a  case  of 
ii'itis  without  the  formation  of  any  posterior  synechite.  Of  course  such 
eyes  do  not  enjoy  a  perfect  immunity  from  a  recurrence  of  iritis  if  a  suffi- 
cient exciting  cause  should  arise,  but  they  are  far  less  prone  to  it  than 
if  adhesions  have  remained  behind.  Irido-choroiditis  may  also  be  caused 
by  injuries  and  wounds  of  the  eye,  by  the  lodgement  of  foreign  bodies 
(more  especially  splinters  of  metal,  gun  caps,  or  glass)  within  the  eye, 
and  by  operations,  particularly  those  for  cataract.  It  may  likewise  arise 
in  consequence  of  an  injury  to  the  other  eye,  thus  constituting  "  sym- 
pathetic ophthalmia." 

If  the  adhesions  between  the  iris  and  capsule  of  the  lens  are  not 
considerable,  and  are  thin  and  "  tongued,"  it  may  be  possible  to  tear 
them  through  by  the  prolonged  use  of  a  strong  solution  of  atropine,  or  to 
separate  them  by  operative  interference  (corelysis).  But  if  they  are 
firm  and  broad,  and  especially  if  they  extend  all  roimd  the  edge  of  the 
pupil,  and  thus  cut  off  the  communication  between  the  anterior  and 
posterior  chamber,  we  must  have  recourse  to  iridectomy,  for  no  other 
means  will  suffice  to  guard  the  eye  against  the  dangers  of  irido-choroi- 
ditis, or  to  stay  the  progress  of  this  disease  if  it  is  already  present. 

In  the  early  stage,  when  the  adhesions  are  not  very  extensive  and 
firm,  and  the  tissue  of  the  iris  has  not  yet  undergone  atrophic  changes, 
it  is  generally  not  difficult  to  obtain  a  tolerably  good  artificial  pupil,  by 
means  of  an  iridectomy.  Frequently,  however,  a  small  rim  of  iris,  at 
the  edge  of  the  pupil,  is  so  firmly  attached  to  the  capsule  as  not  to  yield 
to  the  traction  of  the  forceps,  but  is  left  standing.  This  does  not  invaK- 
date  the  result,  if  a  tolerable  sized  piece  of  iris  is  removed,  and  a  clear 
artificial  pupil  and  a  free  communication  between  the  two  chambers 
are  established.  If  the  pupil  is  only  adherent  at  certain  points,  it  will 
be  best  to  employ  a  fine  blunt  hook,  instead  of  the  ms  forceps,  for 
catching  up  the  iris.  The  hook  is  to  be  passed  carefully  along  to  the 
edge  of  the  pupil  (the  portion  where  there  are  no  synechige),  gently 
turned  over  the  margin,  and  the  iris  then  drawn  out  and  snipped 
off".  In  this  way  we  may  often  succeed  in  excising  a  considerable 
segment  of  the  iris,  whereas  from  the  rottenness  of  its  structure  and 
the  firmness  of  the  adliesions,  it  would  probably  have  resisted  the 
grasp  of  the  forceps,  and  only  small  shreds  have  been  removed.  Care 
must  be  taken  never  to  employ  too  much  force  in  the  removal  of  the 
iris,  otherwise  a  dialysis  may  be  easily  produced  at  the  opposite  circum- 
ference of  the  iris. 

We  generally  find  that  after  the  operation,  the  inflammatory 
symptoms  quickly  subside,  that  the  sight  improves,  and  that  the  recui^- 


miDO-CHOROIDITIS.  191 

rence  of  inflamrQation  is  arrested.  In  some  cases,  however,  this  is 
not  the  case.  Exposure  to  cold,  bright  Hght,  continued  use  of  the  eyes, 
easily  reproduce  an  inflammation.  If  these  recurrences  are  frequent 
and  obstinate,  much  benefit  is  often  derived  from  a  second  iridectomy, 
made  in  an  opposite  dii'ection,  so  that  the  two  halves  of  the  iris  are  com- 
pletely cut  off  from  each  other.  This  operation  has  been  practised  -wdth 
much  success  by  Graefe  and  Critchett  (independently  of  each  other), 
and  I  have  often  found  much  benefit  from  its  performance  in  cases  of 
obstinate  recurrent  iritis.  The  line  of  the  double  iridectomy  may  be 
either  horizontal  or  vertical.  The  advantage  of  the  latter  is,  that  a  more 
or  less  considerable  portion  of  the  upper  part  of  the  artificial  pupil  is 
covered  by  the  upper  Hd,  which  dimuiishes  the  circles  of  diffusion  upon 
the  retina. 

In  tliat  form  of  irido- choroiditis  in  which  the  iris  is  bulged  forward  by 
knob-like  protixberances,  and  the  edge  of  the  pupil  is  tied  down  tightly 
by  a  firm  cu'cular  synechia,  it  is  generally  not  difficult  to  grasp  and 
remove  a  considerable  piece  of  iris,  and  thus  to  form  a  good  sized 
artificial  pupil. 

On  account  of  the  great  shallowness  of  the  anterior  chamber  and 
the  proximity  of  the  bulging  iris  to  the  posterior  portion  of  the  cornea, 
it  is  often  very  difiicult  to  avoid  cutting  the  iris  with  the  common  iri- 
dectomy knife.  It  is  better,  therefore,  to  make  the  incision  with  Von 
Graefe's  long,  narrow  cataract  knife,  for  with  it  we  can  skirt  the  edge 
of  the  chamber  and  gain  a  large  incision  without  any  fear  of  injuring  the 
iris. 

We  unfortunately  not  unfrequently  find  that  although  the  iridectomy 
is  large,  the  sight  is  but  little  if  at  all  improved,  for  the  artificial  pupil  is 
occupied  by  a  thick  uveal  membrane  detached  by  the  fluid  from  the  iris. 
It  is  of  practical  importance  to  remember  the  probability  of  this  occurrence 
on  forming  our  prognosis  as  to  the  effect  of  the  operation  ;  hence  we 
should  never  definitively  promise  the  patient  great  improvement  of  sight 
after  the  first  operation,  but  prepare  him  for  the  probable  necessity  of 
a  second.  The  uveal  pigment  is  so  intimately  connected  with  the  capsule 
of  the  lens,  that  it  is  generally  unwise  to  attempt  to  scrape  a  portion  of 
it  off,  as  rupture  of  the  capsule  and  traumatic  cataract  might  ensue.  If 
we  therefore  find  that  so  considerable  a  portion  of  the  artificial  pupil 
(the  natural  one  being  also  blocked  up  by  lymph)  is  occupied  by  the 
uvea  as  greatly  to  impair  the  sight,  it  will  be  best,  at  a  later  period,  to 
make  another  iridectomy  in  a  different  direction,  in  the  hope  that  at  this 
point  there  may  be  less  deposit  upon  the  capsule.  By  this  means,  or 
even  by  a  third  iridectomy,  we  may  succeed  in  finally  giving  the  patient 
a  good  clear  pupil  and  a  considerable  degree  of  sight.  A  most  interest- 
ng  and  instructive  example  of  this  kind  occurred  amongst  the  patients 
at  Moorfields,  where  Mr.  Bowman  repeated  the   operation ;  performing 


192  DISEASES   OF   THE   IRIS. 

iridectomy  twice  upon  the  right  eye  and  three  times  upon  the  left.  The 
result  was  most  successful.  On  the  patient's  admission  his  sight  was 
as  follows  : — Right  eye,  letters  of  20  (Jager)  with  difficulty,  counts 
fingers  within  18  inches.  Left  eye — counts  fingers  with  uncertainty 
within  3  feet.  Seven  weeks  afterwards,  on  his  discharge  from  the 
hospital,  he  could  read  ISTo.  2  with  the  right  eye  and  No.  12  with  the  left.* 

Even  although  the  first  iridectomy  may  not  materially  improve  the 
sight,  we  find  that  it  generally  exerts  a  beneficial  influence  upon  the 
tissue  of  the  iris  and  the  general  condition  of  the  eye.  The  iris  gradually 
gains  a  more  normal  colour  and  appearance.  Von  Graefe  was  the 
first  to  call  attention  to  the  fact  that  a  certain  degree  of  atrophy  of  the 
eye,  consequent  upon  irido-choroiditis,  may  be  arrested  by  the  per- 
formance of  iridectomy,  and  the  eye  regain  its  normal  tension.  This 
fact  has  since  been  widely  acknowledged  by  all  surgeons  who  have 
much  experience  on  this  subject.  Of  course  the  atrophy  must  not  have 
advanced  too  far,  otherwise  its  arrest  wall  be  impossible,  the  same  being 
the  case  if  detachment  of  the  retina  has  occurred.  The  benefit  derived 
from  ii'idectomy  (perhaps  repeated  several  times)  in  these  cases,  is  that 
the  stasis  and  congestion  in  the  choroidal  vessels  is  relieved,  which  not 
only  causes  an  improvement  in  the  choroidal  circulation,  but  also  in  the 
nutrition  of  the  vitreous  humour. 

If  we  cannot  succeed  in  finding  a  portion  of  capsule  sufficiently  clear 
of  uveal  pigment  to  allow  of  much  improvement  of  sight,  or  if  the  lens 
is  opaque,  it  will  be  best  to  remove  the  latter. 

Whilst  we  may  afford  considerable  improvement  in  the  above  class  of 
cases  from  repeated  iridectomies,  in  the  second  kind  of  irido-choroiditis 
this  is  by  no  means  the  rule.  Although  in  the  former  case  the  first  arti- 
ficial pupil  often  becomes  narrowed  or  even  closed,  yet  the  texture  of 
the  iris  improves  ;  at  a  second  operation  we  mostly  succeed  in  gaining  a 
larger  pupil,  and  at  a  subsequent  one,  a  tolerably  good  result  as  to  the 
sight.  But  when  thick  felt- like  masses  of  exudation  exist  between  the 
iris  and  capsule,  we  fail  to  remove  a  considerable  portion  of  the  rotten 
iris,  and  this  attempt,  moreover,  sets  up  renewed  inflammation,  increased 
proliferation  of  the  exudation  masses,  and  we  thus,  instead  of  improving 
the  condition,  hasten  the  atrophy  of  the  eye.  It  will  therefore  be  neces- 
sary, in  order  to  benefit  such  cases,  to  remove  not  only  the  iris  but  the 
dense  masses  behind  it ;  but  they  are  generally  so  firmly  adherent  to 
the  capsule  that  we  are  almost  sure  to  rupture  the  latter  in  our  en- 
deavour to  remove  them.  A  traumatic  cataract  is  formed,  and  this 
complicates  matters  still  more.  But  Von  Gracfe  had  an  opportunity 
of  seeing  that  these  false  membranes  could  be  removed  with  compara- 

*  I  have  reported  this  case  at  length  iu  the  "  Eoyal  Loudou  Ojihth.  Hosp. 
Reports,"  vol.  iii. 


IRIDO-CHOROIDITIS.  193 

tive  facility  and  success  when  the  lens  was  absent.*  This  led  him  to 
remove  the  lens,  in  the  following  mannei",  prior  to  attempting  the  with- 
drawal of  the  ii'is  and  exudation  masses.  A  large  linear  incision  is  to 
be  made  in  the  sclero-corneal  junction  downwards  with  Graefe's  long, 
narrow  cataract  knife,  avoiding,  if  possible,  to  wound  the  iris ;  but  if 
the  latter  is  greatly  bulged  forwards  the  knife  should  be  passed  boldly 
through  it,  and  this  generally  lacerates  the  capsule  sufficiently  freely  to 
permit  the  ready  exit  of  the  lens.  If  this  is  not  the  case  or  the  iris  has 
been  left  untouched  by  the  knife,  a  pair  of  straight  forceps  or  a  hook 
should  be  introduced,  and  as  much  of  the  iris  and  false  membrane  should 
be  removed  or  torn  away  as  will  allow  the  lens  to  escape.  A  compress 
should  be  applied  after  the  operation,  and  should  be  worn  for  two  or 
three  weeks  if  there  has  been  much  bleeding  into  the  anterior  chamber. 
Sometimes  the  condition  of  the  eye  sensibly  improves  after  the  removal 
of  the  lens,  the  ii*is  assumes  a  better  colour,  the  anterior  chamber  be- 
comes larger,  the  perception  of  light  may  even  improve  a  little.  A 
month  or  six  weeks  after  the  extraction.  Von  Graefe  recommends  the 
iridectomy  to  be  made.  The  incision  should  be  large,  and  a  sharp 
pointed  hook  should  be  passed  perpendicularly  through  the  false  mem- 
branes and  a  hole  torn  in  them  ;  if  a  moderate  clear  black  pupil  results, 
and  the  vitreous  humour  pi-otrudes  through  it  into  the  anterior  chamber, 
the  dilaceration  may  be  considered  sufficient.  If  this  is  not  the  case,  a 
blunt  hook  or  straight  forceps  should  be  introduced,  and  the  opening 
enlarged,  the  same  being  necessary  if  a  secondary  cataract  appears  in  the 
newly-made  pupil.  These  pupils  do  not  generally  close  again,  and  it  is 
surprising  that  the  eye  mostly  bears  these  operations  with  remarkable 
quietude.  Indeed,  eyes  affected  with  chronic  irido-choroiditis  but 
seldom  undergo  suppuration  after  operations.  By  means  of  the  above 
operation  we  are  not  unfrequently  enabled  to  restore  a  useful  degree  of 
sight  to  eyes  otherwise  hopelessly  blind,  the  patient  being  perhaps  able  to 
guide  himself,  to  distinguish  large  letters,  etc. 

The  following  mode  of  operating,  as  practised  by  Mr.  Bowman, 
may  also  be  adopted  with  advantage.  An  incision  is  made  with  an 
iridectomy  knife  in  the  upper  part  of  the  sclero-corneal  junction,  and 
the  knife  is  canned  on  far  into  the  anterior  chamber,  until  its  point 
reaches  the  opposite  side  of  the  iris  just  below  the  lower  edge  of  the 
pupil ;  into  this  part  of  the  iris  a  transverse  cut  is  to  be  made  with  the 
point  of  the  knife.  The  blades  of  a  pair  of  scissors  are  then  introduced 
through  the  incision  in  the  cornea,  the  one  blade  being  passed  in  front, 
the  other  behind  the  iris,  and  a  cut  is  made  straight  through  the  iris 
down  to  the  transverse  incision  below  the  pupil,  a  similar  cut  being 
then  made  on  the  opposite  side,  so  as  to  include  between  the  two  a  large 

*  "Graefe's  Ai-ch.,"  vi,  2,97;  vide  also  the  author's  abstract  of  this  paper  in 
the  "  Kojal  Lond.  Ophth.  Keports,"  vol.  iii,  p.  224. 


194  DISEASES   OF   THE  IRIS. 

lozenge- shaped  piece  of  iris  together  with  the  whole  pupillary  edge, 
which  is  then  to  be  seized  with  a  pair  of  forceps  and  drawn  out  through 
the  incision.  The  capsule  may  then,  if  necessary,  be  widely  lacerated, 
and  the  lens  matter  be  removed  by  Critchett's  cataract- spoon.  A 
considerable  portion  of  the  capsule  is,  however,  generally  torn  away 
together  with  the  iris.  We  may  finally  again  introduce  the  scissors 
and  divide  the  lower  segment  of  the  iris,  so  as  completely  to  separate 
the  two  lateral  halves. 


11.— SYMPATHETIC  OPHTHALMIA. 

The  name  of  sympathetic  ophthalmia  was  first  applied  by  Mackenzie 
to  those  cases  in  which  an  injury  of  the  one  eye  was  followed  by  a 
peculiar  inflammation  in  the  other,  which  generally  ensues  within  a 
short  time  of  the  accident,  and  proves  extremely  dangerous  and  in- 
tractable. That  such  a  sympathy  exists  between  the  two  eyes  had, 
however,  been  previously  pointed  out  by  Himly  and  Beer. 

The  character  of  sympathetic  inflammation  is  so  extremely  danger- 
ous and  insidious,  that  if  it  has  once  been  lit  up,  we  are  but  seldom 
able  to  stay  its  progress  before  great,  and  often  irreparable,  mischief,  has 
been  done.  In  the  great  majority  of  cases  the  disease  shows  itself  in 
the  form  of  a  very  malignant  irido-cyclitis,  accompanied  by  great 
degeneration  of  the  iris,  total  exclusion  of  the  pupil,  and  the  formation 
of  dense  masses  of  exudation  between  the  posterior  surface  of  the  iris 
and  the  capsule  of  the  lens.  This  is  the  "  sympathetic  ophthalmia  " 
par  excellence,  but  it  occasionally  appears  in  a  more  tractable  and 
benign  form,  assuming  the  character  of  serous  iritis.  Von  Graefe 
has,  moreover,  observed  a  third  and  still  more  rare  afiection,  viz., 
sympathetic  choroido-retinitis. 

It  is  of  practical  importance  to  distinguish  the  condition  of  sym- 
pathetic irritation,  which  sometimes  ensues  upon  an  injury  or  inflamma- 
tion of  the  one  eye,  from  sympathetic  ophthalmia.  In  the  former  case, 
the  patient  finds  that  any  inflammatory  exacerbation  of  the  injured  eye  is 
accompanied  by  more  or  less  irritability  of  the  other.  He  is  unable  to 
employ  the  latter  in  reading  or  fine  work,  without  its  soon  becoming 
tired  and  strained,  owing  to  an  impairment  of  the  power  of  accommo- 
dation. The  range  of  accommodation  is  generally  also  markedly 
diminished,  the  near  point  being  removed  further  from  the  eye.  Every 
accommodative  effort  causes  the  eye  to  flush  up  and  become  irritable,  a 
bright  rosy  zone  appears  around  the  cornea,  and  photophobia  and 
lachrymation  soon  supervene,  together  with  more  or  less  ciliary  neu- 
ralgia.    These  symptoms  generally   subside,   more   especially   at   the 


I 


SYMPATHETIC  OPHTHALMIA.  195 

commencement,  as  soon  as  the  work  is  laid  aside,  but  quickly  re- 
appear on  its  being  resumed,  or  when  tlie  eye  is  exposed  to  cold,  bright 
light,  etc.  The  injured  eye,  moreover,  often  also  becomes  painful  and 
irritable  when  the  other  is  used  for  reading  or  sewing.  Bonders 
describes  a  form  of  severe  sympathetic  irritation  under  the  name  of 
•"  sympathetic  neurosis."  It  is  particularly  distinguished  by  the  in- 
tensity of  the  photophobia  and  lachrymation,  these  symptoms  being 
often  so  severe  as  to  cause  a  violent  spasm  of  the  lids,  and  directly 
any  attempt  is  made  to  open  the  eye  a  stream  of  scalding  tears  pours 
over  the  cheek.  There  is,  however,  no  impairment  of  sight,  although 
from  its  great  irritability  the  eye  is  quite  unfit  for  use.  Bonders  con- 
siders that  this  neurosis  never  passes  over  into  sympathetic  ophthalmia, 
and  yields  in  a  very  rapid  and  marked  manner  to  the  removal  of  the 
injured  eye.  Whether  or  not  cases  of  sympathetic  irritation  are  to  be 
regarded  in  the  light  of  a  premonitory  stage  of  sympathetic  ophthalmia, 
or  whether  they  are  to  be  looked  upon  as  completely  differing  from  it 
in  character,  and  as  never  liable  to  pass  over  into  it,  is  at  present,  I 
think,  an  open  question.  Whilst  on  the  one  hand,  it  must  be  admitted  that 
we  occasionally  meet  with  instances  in  which  a  state  of  great  irritability 
has  existed  for  a  long  time  without  setting  up  sympathetic  ophthalmia, 
yet  on  the  other,  it  must  also  be  conceded,  that  the  attack  of  inflammation 
is  often  shown  to  have  been  clearly  preceded  by  symptoms  of  irritation. 
Although  this  question  is  one  of  much  interest  and  importance  in  the 
study  of  the  true  nature  of  sympathetic  inflammation,  it  is  fortunately 
of  but  little  consequence  in  the  treatment.  For  I  think  there  can  be 
no  doubt  that  the  proper  mode  of  deahng  with  a  case  in  which  marked 
and  persistent  symptoms  of  sympathetic  irritability  appear,  is  the 
immediate  removal  of  the  injured  eye,  more  especially  if  its  sight  is  lost 
or  very  much  impaired.  Indeed,  it  would  be  incurring  unnecessary  risk 
to  neglect  doing  so,  on  the  supposition  that  the  state  of  irritation  would 
never  pass  over  into  that  of  inflammation. 

Si/mpathetie  irido-cijcUtis  is  characterised  by  all  the  symptoms  of  a 
severe  intra-ocular  inflammation.  The  eyelids  are  somewhat  red  and 
swollen,  and  there  is  more  or  less  photophobia,  lachrymation,  and  ciliary 
neuralgia.  Sometimes,  how^ever,  there  is  not  the  shghtest  pain,  so  that 
even  in  children  we  hear  no  complaint,  and  this  invests  the  disease  with 
a  peculiarly  dangerous  character,  as  it  is  very  apt  to  be  long  unnoticed 
by  the  parents.  The  ciliary  region  is  generally  sensitive  to  the  touch, 
and  often  acutely  so.  Soon  there  appear  some  peri-corneal  vascularity 
and  chemosis,  the  ii'is  becomes  discoloured,  and  of  a  yellowish-red  tint, 
the  aqueous  humour  is  clouded,  and  the  anterior  chamber  perhaps 
diminished  in  depth.  There  is  a  rapid  efiusion  of  lymph  at  the  edge  of 
the  pupil,  soon  leading  to  its  complete  exclusion ;  indeed  the  action  of 
atropine  exerts  but  little  influence  upon  the  pupil.     But  the  exudation 

0  2 


196  DISEASES  OF   THE  IRIS. 

is  not  confined  to  the  pupillary  edge,  but  extends  to  the  posterior 
surface  of  the  iris  and  the  ciHary  processes.  The  iris  becomes  firmly 
glued  down  to  the  capsule  of  the  lens,  and  as  the  disease  advances, 
these  exudations  assume  a  very  dense,  firm,  and  organized  character. 
Lymph  is  also  effused  upon  the  surface  and  into  the  stroma  of  the  ins, 
often  to  such  an  extent  that  the  latter  appears  soaked  in  it.  The  pupil 
is  either  covered  by  a  film  of  exudation,  or  may  be  completely  occluded 
by  a  dense  yellow  nodule.  On  account  of  the  inflammatory  swelling 
of  the  ciliary  body,  this  region  is  very  sensitive  to  the  touch,  and  the 
circulation  of  the  iris  is  greatly  impeded,  and  the  venous  efflux  ob- 
structed ;  hence  we  soon  notice  the  appearance  of  large  tortuous  vems 
upon  the  iris.  Its  structm^e  soon  becomes  degenerated  and  changed 
into  a  firm,  tense,  fibrillar  tissue,  which  cannot  be  caught  up  in  a  fold 
by  the  iridectomy  forceps,  but  is  so  friable  and  rotten  that  it  tears  and 
breaks  down  under  their  grasp.  Hence  if  an  iridectomy  is  attempted, 
we  shall  only  succeed  in  tearing  away  a  small  portion  of  the  iris,  and 
probably  set  up  fresh  inflammation,  w^hich  will  lead  to  a  rapid  increase 
in  the  density  and  extent  of  the  exudation-masses.  If  the  pupil  and 
refracting  media  are  sufficiently  clear  to  permit  of  the  use  of  the 
ophthalmoscope,  we  may  notice  opacities  in  the  vitreous  humour,  and 
inflammatory  changes  in  the  choroid  and  retina.  Or  there  may  be  dense 
masses  of  exudation  in  the  anterior  portion  of  the  vitreous  humour, 
giving  rise  to  a  peculiar  yellow  lustrous  reflex.  At  a  later  stage  of  the 
disease,  when  the  morbid  products  have  become  more  consolidated,  the 
periphery  of  the  iris  is  often  drawn  back,  which  is  due  to  a  direct 
retraction  caused  by  the  adhesion  of  its  posterior  surface  to  the  ciliary 
processes  (Graefe*).  Whereas,  on  account  of  the  increase  in  the 
exudation  behind  the  iris,  the  latter,  and  with  it  the  lens,  is  moved 
forward.  So  that  the  more  central  portion  of  the  iris  and  the  pupil 
are  approached  nearer  the  cornea  and  the  anterior  chamber  narrowed, 
whilst  the  periphery  of  the  iris  may  be  drawn  back  towards  the  ciliary 
body.  In  other  cases  fluid  is  effused  behind  the  iris,  and  the  latter 
becomes  bulged  out  into  little  protuberances.  The  attack  is  often  so 
insidious  and  painless,  that  the  patient  pays  but  little  heed  to  the  first 
stage  of  the  inflammation,  thinking  perhaps  that  he  has  only  caught  a 
slight  "  cold  "  in  the  eye  ;  and  it  is  not  till  the  sight  becomes  materially 
affected  that  he  is  frightened  and  seeks  medical  aid.  In  children 
especially  (from  their  taking  but  little  heed  of  the  impairment  of  sight 
and  from  the  absence  of  pain),  the  disease  is  sometimes  allowed  to 
proceed  very  far  indeed  before  much  attention  is  paid  to  it  by  the 
parents.  But  although  the  spontaneous  pain  is  often  absent,  we  find 
that  the  region  of  the  ciliary  body  is  generally  very  sensitive  to  the 
touch,  and  sometimes,  as  has  been  pointed  out  by  Bowman  and  Von 

*  "A.  f.  0.,"iii,  2,  151. 


SYMPATHETTO   OPHTHALMIA.  197 

Graefe,  at  a  spot  corresponding  symmetrically  to  the  point  at  which  the 
other  eye  has  been  injured,  or  where  it  still  remains  tender  to  the 
touch. 

The  tension  of  the  eye  varies  considerably  ;  at  first  it  is  generally 
more  or  less  increased,  but  then  it  gradually  diminishes  until  the  eye 
becomes  quite  soft,  being  still,  however,  liable  to  considerable  fluctua- 
tions in  consistence.  It  is,  moreover,  a  fact  of  great  practical  import- 
ance, that  if  such  eyes  are  left  alone,  and  the  acme  of  the  inflammatory 
process  is  allowed  to  subside,  and  the  eye  to  become  quiet,  that  gradu- 
ally and  slowly  its  condition  often  begins  to  improve.  The  tension 
becomes  better,  and  gi^adually  augments  until  it  may  even  reach  the 
normal  standard ;  the  tissue  of  the  iris  improves  greatly  in  appear- 
ance, loses  its  dirty  yellow  hue,  and  assumes  a  fresher  and  more  normal 
tint. 

Li  the  sympathetic  serous  iritis  we  find  that  the  symptoms  are  very 
different,  and  closely  resemble  those  of  serous  iritis,  or  serous  irido- 
cyclitis. Together  with  a  certain  degree  of  ciliary  injection,  we  notice 
that  the  iris  is  somewhat  discoloured,  the  pupil  perhaps  dilated,  the 
aqueous  humour  faintly  clouded,  and  the  posterior  surface  of  the 
cornea  dotted  by  innumerable,  small,  punctiform  opacities,  which  are 
perhaps  arranged  in  the  form  of  a  pyramid,  having  its  base  downwards. 
The  depth  of  the  anterior  chamber  may  be  increased.  If  the  inflam- 
mation has  extended  to  the  ciliary  body,  this  is  sensitive  to  the  touch, 
and  the  vitreous  humour  is  also  clouded.  The  intra-ocular  tension  is 
often  augmented.  This  form  is  much  less  common,  and  much  less 
dangerous  than  sympathetic  irido-cyclitis. 

Von  Graefe*  describes  another  and  very  rare  form  of  sympathetic 
ophthalmia,  under  the  name  of  '■''sympathetic  choroido-7'etmitis,"  and 
narrates  two  cases,  illustrative  of  the  symptoms  presented  by  it.  In 
one  of  these,  the  patient  had  a  dislocated  chalky  lens  lying  in  the 
anterior  chamber  of  the  left  eye,  which  was  perfectly  blind,  and  some- 
what atrophied.  The  lens  was  removed  with  facility  by  Von  Graefe, 
but  the  operation  was  accompanied  by  a  considerable  loss  of  fluid, 
yellow  vitreous  humour.  The  eye  remained  irritable,  red,  and  very 
sensitive  to  the  touch  for  several  weeks,  and  there  were,  moreover, 
symptoms  of  plastic  cyclitis.  Six  weeks  after  the  operation,  when 
these  symptoms  had  somewhat  subsided,  but  the  sensibility  to  the 
touch  still  remained,  the  sight  of  the  right  eye,  which  had  hitherto 
been  perfectly  good,  began  siiddenly  to  be  impaired,  but  this  was  unac- 
companied by  any  pain.  The  acuity  of  vision  had  already  on  the 
second  day  after  the  attack  sunk  to  one-fifth,  and  there  was  consider- 
able torpor  of  the  retina,  with  indistinctness  of  eccentric  vision  on  the 
whole  of  the  temporal  half  of  the  visual  field.  With  the  ophthalmo- 
*  "Arcliiv.  f.  O.,"  xii,  2,  171. 


198  DISEASES   OF   THE   IRIS. 

scope,  the  retinal  veins  were  seen  to  be  very  tortuous  and  dilated,  more 
especially  on  tlie  inner  side.  The  retina  also  showed  a  delicate  and 
diffuse  cloudiness,  which  not  only  veiled  the  choroidal  ring  of  the  optic 
nerve,  but  extended  to  certain  portions  of  the  retina,  especially  along 
the  coui'se  of  some  of  the  larger  retinal  vessels.  Slight  symptoms  of 
iritis  soon  siipervened,  and  very  delicate  punctiform  opacities  were 
observed  on  the  membrane  of  Descemet.  The  power  of  accommodation 
was  almost  completely  paralysed.  These  symptoms  gradually  subsided, 
and  the  sight  became  finally  quite  restored.  Whether  this  favourable 
result  was  chiefly  due  to  the  remedial  measures  employed  (local  deple- 
tion, bichloride  of  mercury,  and  afterwards  iodide  of  potassium),  or  to 
the  extinction  of  the  sensibility  of  the  left  eye  to  the  touch  was  uncer- 
tain. Von  Graefe  himself  lays  the  greater  stress  upon  the  last  fact. 
The  morbid  appearances  of  the  retina  disappeared  less  rapidly  than  the 
functional  disturbances,  and  then  there  were  noticed  patches  of  cho- 
roiditis. 

Causes  of  sympathetic  ophtlialmia. — 1.  Amongst  the  most  frequent 
causes  are  injuries  to  the  eye,  such  as  punctured  and  incised  wounds, 
more  especially  in  the  region  of  the  ciliary  body. .  If  such  wounds  are 
extensive,  the  lens  has  generally  escaped,  accompanied  perhaps  by  con- 
siderable loss  of  vitreous  and  extensive  intra-ocular  haemorrhage.  Small 
incised  wounds  of  the  ciliary  region,  or  situated  partly  in  the  latter  and 
partly  in  the  cornea,  are  not  necessarily  of  so  dangerous  a  character, 
more  especially  if  they  have  only  penetrated  the  coats  of  the  eye 
without  injury  of  the  lens  or  vitreous  humour.  In  such  cases,  no  time 
should  be  lost  in  bringing  the  lips  of  the  little  wound  together  with  a 
suture.  Union  by  the  first  intention  will  take  place,  and  many  an  eye 
will  thus  be  saved,  which  might  otherwise  have  not  only  been  itself  lost 
from  choroiditis,  but  might  have  also  proved  a  source  of  danger  to  the 
other  eye.  In  wounds  which  implicate  the  cornea  alone,  there  is  gene- 
rally not  much  danger  of  sympathetic  ophthalmia,  although,  if  they  are 
accompanied  by  a  considerable  prolapse  of  the  iris,  and  this  is  situated 
near  the  periphery,  it  may,  by  dragging  upon  and  irritating  the  ciliary 
processes,  set  up  sympathetic  ophthalmia.  But  when  there  has  been  a 
penetrating  wound  of  the  cornea  (such  as  may  be  produced  by  a  pair 
of  scissors),  and  the  iris  and  lens  have  been  also  injured,  there  is 
always  some  risk.  The  disease,  may,  moreover,  be  likewise  produced 
by  severe  contusions  of  the  eye. 

2.  Foreign  bodies  lodged  within  the  eye,  ai'e  a  most  frequent  cause. 
Amongst  these  we  must  especially  enumerate  portions  of  gun  cap  or  of 
metal,  and  splinters  of  glass  or  stone.  They  prove  a  source  of  con- 
stant irritation  to  the  eye,  more  especially  if  they  are  considerable 
in  size,  and  differ  in  their  chemical  constituents  from  the  structures 
in  which  they  are  embedded.     Inflammation  of  the  iris  and  choroid 


SYMPATHETIC  OPHTHALMIA.  199 

supervene,  and  the  eye  may  become  gradually  atrophied,  shrinking 
down  to  a  small  shrivelled  stump.  But  even  then,  all  danger  to  the 
other  eye,  if  this  has  hitherto  escaped,  is  by  no  means  passed,  for  such 
stumps  are  a  soui'ce  of  constant  risk,  as  long  as  they  remain  painful  to 
the  touch,  and  show  signs  of  irritability.  Years  may  elapse  after  the 
injury,  and  the  patient  have  long  since  forgotten  his  surgeon's  admonition 
as  to  the  danger  to  the  other  eye,  when  suddenly  the  latter  becomes  sym- 
pathetically inflamed,  and  in  spite  of  all  our  efforts,  perhaps  destroyed. 
Mr.  Lawson,  in  his  valuable  work  on  "Injuries  of  the  Eye,"*  narrates 
two  very  interesting  and  important  cases  of  this  kind,  cases  which 
should  indelibly  imprint  themselves  upon  our  memory,  in  order  that  we 
may  know  how  to  decide  on  an  emergency,  as  to  the  advisability  of  the 
immediate  removal  of  an  eye  having  a  foreign  body  lodged  within  it, 
and  which  it  is  impossible  to  extract.  One  of  the  patients  was  injured  in 
the  left  eye,  by  the  explosion  of  a  gun  cap,  in  1857.  The  accident  was 
followed  by  inflammation  and  suppuration  of  the  injured  eye,  which 
shrivelled  up  to  a  small  stump,  with  the  foreign  body  probably  still 
lodged  within  it.  But  the  stump  was  quiescent,  and  gave  no  trouble. 
The  sight  of  the  right  eye  remained  perfect  up  to  February,  1865  (seven 
years  after  the  injury),  when  it  became  dim,  but  the  patient  experienced 
no  pain  in  it.  The  stump  had,  however,  become  painful  and  inflamed 
some  time  previously. 

Repeated  attacks  of  inflammation  occurred  in  the  right  eye  be- 
tween this  time  and  September  of  the  same  year,  when  he  first  applied 
to  Mr.  Lawson,  who  then  found  it  afiected  with  marked  sympathetic 
ophthalmia,  and  the  sight  so  much  impaired,  that  he  could  not  count 
fingers.  The  stump  of  the  left  eye  was  inflamed,  red,  and  irritable,  and 
was  at  once  excised,  and  within  it,  near  the  cicatrix  in  the  front,  was 
found  the  percussion  cap.  The  right  eye  improved  decidedly  after  the 
operation. 

The  second  patient  was  under  Mr.  Couper.  His  right  eye  was  lost 
by  injury  from  a  gun-cap,  in  1850.  Fourteen  years  after  the  injury 
(1864)  the  injured  eye  became  again  painful  and  inflamed,  and  now  the 
left  was  affected  with  sjTnpathetic  ophthalmia.  He  applied  six  months 
later  at  the  Royal  London  Ophthalmic  Hospital,  and  Mr.  Couper  found 
that  the  sympathetic  inflammation  had  proceeded  so  far  that  the 
patient  could  scarcely  distinguish  a  hand  with  the  left  eye.  The 
right  was  at  once  excised,  and  a  small  chip  of  gun- cap  was  found 
embedded  in  lymph,  and  lying  on  the  ciliary  processes  ;  the  retina 
was  detached. 

3.  Sympathetic  ophthalmia  may  also  be  caused  by  internal  inflam- 
mations of  the  eye,  more  especially  if  they  are  accompanied  by  hemorr- 
hagic   effusions,     either   considerable    in    quantity,     or    of    frequent 

*  P.  321—323. 


200  DISEASES   OF   THE  IRIS. 

recurrence,  togetlier  with  rapid  fluctuations  in  the  intra-ocular 
tension.  Also  if  a  bony  deposit  in  the  choroid  has  occurred,  and  the 
eye  remains  irritable  to  the  touch.  Indeed  the  continuance  of  sen- 
sibility in  the  region  of  the  ciliary  body  in  cases  of  irido- choroiditis, 
or  in  eyes  which  have  undergone  atrophy  after  internal  inflammation, 
is  one  of  the  most  dangerous  symptoms,  as  such  eyes  are  extremely 
prone  to  set  up  sympathetic  ophthalmia. 

Mooren*  mentions  a  very  interesting  case  in  which  the  sympathetic 
ophthalmia  was  apparently  produced  by  the  contusion  of  the  optic 
nerve  in  dividing  it  with  the  scissors  in  excision  of  the  eye. 

Some  observers  are  inclined  to  push  the  causation  of  sympathetic 
ophthalmia  much  further  than  I  have  done  ;  but  I  believe  that  I  have 
above  enumerated  most,  if  not  all,  the  causes  which  have  been  sufii- 
ciently  authenticated,  as  giving  rise  to  sympathetic  disease.  It  must 
be  granted,  however,  that  when  one  eye  is  utterly  lost  {e.g.,  ft'om  abso- 
lute glaucoma,  from  intra-ocular  haemorrhage,  or  from  irido- choroiditis 
after  unsuccessful  operations  for  cataract,  etc.),  and  remains  painful  and 
irritable,  that  the  removal  of  this  eye  afibrds  a  much  better  prognosis 
for  any  operation  (for  instance,  for  cataract)  upon  the  other,  than  if  it 
be  allowed  to  remain  and  prove  a  constant  source  of  irritation. 

It  was  formerly  generally  supposed  that  sympathetic  ophthalmia 
was  propagated  from  the  injured  eye  to  its  fellow  through  the  optic 
nerves,  by  way  of  the  optic  commissure.  But  this  view  has  been  long 
abandoned  as  untenable,  for  cases  of  sympathetic  ophthalmia  have 
occurred  in  eyes  in  which  the  optic  nerves  were  not  bnly  completely 
atrophied,  but  had  even  undergone  extensive  chalky  degeneration.  It  is 
now  generally  held  that  the  sympathy  is  propagated  by  the  ciliary 
nerves,  and  this  view  certainly  receives  the  strongest  support  from  many 
clinical  facts.  Thus  we  not  unfrequently  meet  with  cases,  as  has  been 
especially  pointed  out  by  Bowman  and  Von  Graefe,  in  which  the  start- 
ing point  of  the  sympathetic  irritation  or  inflammation  in  the  second 
eye  occurs  at  a  spot  of  the  ciliary  region  which  corresponds  symmetri- 
cally to  that  at  which  the  injured  eye  was  hurt,  or  at  which  the  ciliary 
region  still  retains  its  sensibility  to  the  touch.  Moreover,  as  Von  Graefe 
strongly  insists,  the  danger  of  the  sympathetic  ophthalmia  should  never 
be  considered  as  passed,  as  long  as  the  ciliary  region  of  the  injured  eye, 
or  its  stump,  remains  sensitive  to  the  touch,  more  especially  if  it  is 
accompanied  by  diminished  tension,  for  it  is  then  a  symptom  of  plastic 
cyclitis. 

Again,  when  suppuration  of  the  eyeball  occurs,  and  the  ciliary  nerves 
are  destroyed  by  it,  there  is  no  tendency  to  sympathetic  ophthalmia. 
It  is  a  well  known  fact  that  the  latter  is  never  set  up  by  eyes  lost  from 
*  "  Oplitlialiuiatrisclie  Beobachtungen,"  p.  160. 


SYMPATHETIC   OPHTHALMIA.  201 

general  suppuration   (panophthalmitis),  as,  for  instance,  after  opera- 
tions. 

The  prognosis  of  sympathetic  ophthalmia  is  most  unfavourable,  if  the 
disease  has  once  fairly  broken  out.  In  the  stage  of  sympathetic  irri- 
tation the  removal  of  the  injured  eye  arrests  the  progress  ;  but  it  is  quite 
different  if  the  inflammation  has  already  set  in,  more  especially  if  it 
assumes  the  character  of  plastic  irido-cyclitis.  For  then,  even  the  im- 
mediate enucleation  of  the  other  eye  generally  fails  to  have  any,  or  any 
but  a  temporary  beneficial  effect.  For  a  few  days  or  weeks  the  inflam- 
mation appears  to  be  diminished,  but  then  it  breaks  out  again  with  all 
its  former  severity.  The  serous  sympathetic  iritis,  being  more  benign 
in  character  and  more  amenable  to  treatment,  affords  a  more  favourable 
prognosis. 

Sympathetic  ophthalmia  is  more  prone  to  attack  youthful  indi- 
viduals, than  middle-aged  or  elderly  persons.  Its  course  also  appears 
to  be  more  rapid  in  the  young.  It  generally  occurs  witliin  a  few  weeks 
of  the  injury,  but  a  long  period,  even  many  years,  may  elapse  before  it  is 
excited,  as  for  instance,  in  the  cases  above  cited  from  Mr.  Lawson's  work. 

Treatment. — With  regard  to  the  general  treatment  of  sympathetic 
ophthalmia,  I  must  strongly  insist  upon  the  necessity  of  complete  rest  of 
the  eye  for  a  prolonged  period,  and  this  is  to  be  continued  for  some 
length  of  time  after  the  eye  appears  to  have  recovered  from  the  inflam- 
matory attack.  Otherwise,  there  is  the  greatest  danger  of  a  recurrence, 
which  may  prove  most  dangerous  and  intractable.  Whilst  the  eye 
remains  irritable,  the  patient  should  be  confined  to  a  darkened  room, 
and  if  he  has  to  go  into  the  open  air,  the  eye  should  either  be  pro- 
tected by  a  bandage,  by  a  pair  of  dark  blue  eye-protectors,  or  the  wire 
goggles.  In  order  to  allay  the  irritability  of  the  eye,  poppy  or  bella- 
donna fomentations  may  be  applied,  as  also  a  solution  of  atropine 
(varying  from  ij  to  iv  grains  to  the  ounce  of  water),  which  should  be 
dropped  into  the  eye  several  times  a  day.  At  the  very  outset  of  the 
disease  we  shoiild  endeavour  to  gain,  if  possible,  a  wide  dilatation  of  the 
pupil,  and  hence  apply  it  more  frequently  and  in  a  strong  solution  ;  but 
as  has  already  been  stated  above,  the  pupil  is  generally  very  imperfectly 
acted  upon  by  atropine,  and  at  a  later  stage,  the  adhesions  to  the  capsule 
are  so  firm  and  extensive  as  completely  to  resist  its  action. 

The  diet  should  be  nutritious  and  generous,  more  especially  if  the 
patient  is  feeble  and  ill-nourished.  Tonics,  more  particularly  quinine 
and  preparations  of  steel,  should  also  be  administered. 

We  have  now  to  consider,  in  the  first  place,  whether  we  are  enabled 
by  any  operative  interference  to  prevent  the  occurrence  of  sympathetic 
ophthalmia ;  and,  secondly,  whether  we  can  ari"est  its  progress  when  it 
has  once  broken  out. 

With  regard  to  the  first  point,  I   may  state  that,  as  far  as  I  am 


202  DISEASES   OF   THE   IRIS. 

aware,  no  instance  has  been  recorded  in  whicli  sympathetic  ophthalmia 
ever  attacked  an  eye  after  the  injured  eye  had  been  removed,  if  at  the 
time  the  other  was  still  quite  unaffected.  This  being  so,  there  cannot 
be  the  slightest  doubt  as  to  the  imperative  advisability  of  the  immediate 
removal  of  an  eye  which  has  been  so  greatly  injured  as  to  have  quite 
lost  its  sight,  or  at  all  events  to  leave, no  hope  of  any  restoration  of  a 
useful  degree  of  vision.  This  is  still  more  the  case,  if  the  injury  has 
been  of  a  kind  which  is  prone  to  be  followed  by  sympathetic  ophthalmia. 
For  we  have  no  guarantee  that  we  shall  have  time  to  check  the 
sympathetic  inflammation,  if  it  has  once  broken  out,  even  by  a  speedy 
removal  of  the  injured  eye.  For  although  symptoms  of  sympathetic 
irritation  not  unfrequently  usher  in  the  inflammation,  and  the  latter 
may  be  prevented  by  the  excision  of  the  injured  eye  at  this  premonitory 
stage,  yet  this  is  not  always  the  case.  The  inflammation  may  occur 
without  any  premonitory  symptoms,  and  advance  so  rapidly  that  in  the 
course  of  a  few  days  the  integrity  of  the  eye  may  be  greatly  and  per- 
haps permanently  impaired.  Thus,  a  case  is  narrated  by  Maats,  in 
which  within  four  days  (and  without  any  premonitory  symptoms)  an  eye 
became  so  affected  by  sympathetic  irido-cyclitis,  that  there  was  nearly 
a  complete  posterior  synechia,  and  the  sight  had  sunk  to  -^%o.  In  spite 
of  the  immediate  removal  of  the  injured  eye,  and  of  every  endeavour  to 
improve  the  condition  of  the  other  by  iridectomy,  and  subsequently  by  a 
second  iridectomy,  with  removal  of  the  lens,  the  eye  became  atrophied, 
and  only  retained  perception  of  light.  Such  a  case  should  warn  us  of 
the  danger  of  procrastination  in  excision  of  the  blind  injured  eye,  in  the 
hope  that  there  will  always  be  time  enough  for  this  when  symptoms  of 
sympathetic  irritation  manifest  themselves  or  during  the  earliest  stage 
of  sympathetic  inflammation.  For  the  former  may  never  occur,  and  the 
latter  may  be  so  rapid  in  its  development  and  course,  that  great  and 
irremediable  mischief  may  be  done  before  we  can  enucleate  the  other 
eye.  Moreover,  there  is  another  point  which  weighs  heavily  in  the 
scale  amongst  persons  whose  livelihood  depends  upon  their  work,  and 
that  is  the  long  time  which  is  lost  by  them  during  the  treatment  of  the 
injured  eye.  For  it  may  remain  painful  and  irritable  for  many  months, 
and  thus  render  the  patient  quite  unfit  to  use  the  sound  eye.  It  may 
be  laid  down  as  a  fundamental  rule,  that  as  long  as  the  injured  eye  re- 
mains painful  to  the  touch  it  is  always  a  source  of  danger,  and  may  at 
any  moment  set  up  sympathetic  ophthalmia.  It  should  consequently 
be  removed  if  its  sight  is  lost,  or  greatly  and  irremediably  impaired, 
this  being  particularly  indicated  if  a  foreign  body  remains  within  the 
eye.  For  thus  only  can  we  insure  the  patient  against  the  dangers  of 
sympathetic  inflammation.  The  question  as  to  whether  the  injured  eye 
should  be  removed  if  it  still  retains  some  degree  of  vision  is  of  course 
much  more  difficult  and  embarrassing.    In  deciding  upon  this  point,  we 


SYMPATHETIC  OPHTHALMIA.  203 

must  be  chiefly  guided  by  the  nature  and  extent  of  tbe  injury.  Thus, 
if  it  is  a  small  incised  Avound  of  the  cornea  or  sclerotic,  and  the  iris, 
lens,  and  vitreous  humour  have  escaped  any  severe  injury,  we  may  by 
careful  and  judicious  treatment  avoid  the  danger  of  sympathetic  inflam- 
mation, and  ultimately,  perhaps,  restore  excellent  vision.  But  if  the 
wound  is  very  extensive,  and  implicates  the  ciliary  region  and  sclerotic, 
if  the  lens  has  been  lost  or  is  injured,  a  considerable  amount  of  vitreous 
has  escaped,  or  intra-ocular  haemorrhage  has  occurred,  and  if,  con- 
sequently, the  injuries  are  so  great  that  but  very  little,  if  any  sight 
can  possibly  be  saved,  it  is  much  better  to  remove  the  eye  at  once,  even 
although  some  degree  of  vision  may  still  exist.  Still  more  imperative  is 
such  a  coursej  if  these  extensive  injuries  are  due  to  a  foreign  body  which 
has  become  lodged  in  the  eje  and  cannot  be  removed  by  operation,  for 
although  rare  instances  occur  in  which  foreign  bodies  remain  encapsuled 
amd  quiescent  within  the  eye,  such  cases,  form,  unfortunately,  the  great 
exception.  I  would  especially  urge  the  necessity  for  the  operation  if 
the  patient  resides  at  a  distance  fi'om  medical  aid,  so  that  a  careful 
watch  cannot  be  kept  over  the  eye,  and  the  first  symptoms  of  sympa- 
thetic irritation  or  inflammation  be  at  once  detected.  The  question  in 
all  such  cases  is,  whether  it  is  not  better  to  sustain  a  small  loss  than  to 
run  the  risk  of  a  very  great  danger.  I,  however,  fully  feel  and  admit  the 
heavy  responsibility  which  rests  upon  the  siirgeon  who  shall  advise  the 
removal  of  an  eye  which  still  possesses  some  sight,  and  when,  as  yet,  no 
symptoms  of  sympathetic  disease  have  appeared.  We  can  in  such 
cases  only  carefully  and  conscientiously  weigh  the  diiferent  bearings  of 
the  case,  and  place  them  clearly  and  forcibly  before  the  patient  and  his 
friends,  and  leave  the  decision  in  their  hands.  1  have  entered  some- 
what at  length  upon  this  part  of  the  subject,  because  I  feel  it  to  be  of 
great  importance  to  all  medical  men,  and  one  upon  which  they  should 
hold  strong  and  decided  views.  For  we  never  know  at  what  moment 
we  may  not  be  called  upon  to  decide  a  question  of  this  kind,  and  what 
reproaches  we  may  not  have  to  make  ourselves  if  by  our  procrastination 
and  indecision  the  second  eye  is  lost  from  sympathetic  ophthalmia. 

We  must  now  pass  on  to  the  consideration  of  the  question,  as  to 
whether  we  have  any  power  of  checking  the  progress  of  sympathetic 
inflammation  if  it  has  once  broken  out.  If  the  sight  of  the  injured  eye 
is  lost,  it  should  be  at  once  removed,  for  even  although  this  proceeding 
may  not  always  stop  the  progress  of  the  sympathetic  disease,  but  only 
perhaps  arrest  it  for  a  time,  it  will  probably  at  least  exert  a  favourable 
influence  upon  its  course,  from  the  removal  of  the  primary  source  of  irrita- 
tion. But  it  will  be  difierent  if  some  degree  of  sight  still  lingers  in  the 
injured  eye,  more  especially  if  the  sympathetic  inflammation  has  already 
produced  extensive  injury,  for  then  it  must  be  borne  in  mind  that  in  some 
similar  cases  the  injured  eye  eventually  proved  of  the  most  use  to  the 


204  DISEASES   OF   THE  IRIS. 

patient,  lie  having  more  siglit  in  it  than  in  the  other.  It  appears  cer- 
tain, from  the  experience  of  all  authorities  upon  the  subject  of 
sympathetic  ophthalmia  (amongst  whom  I  would  especially  enumerate 
Mackenzie,  Bowman,  Critchett,  Graefe,  Lawson,  Donders,  Pagenstecher) 
that  any  operative  interference  upon  the  second  eye  during  the  progress 
of  the  sympathetic  inflammation  is  not  only  not  beneficial,  but  even  does 
positive  harm,  in  increasing  the  inflammatory  proliferation  of  the 
exudation  masses  behind  the  iris,  and  thus  hastening  instead  of  arresting 
the  progress  of  the  disease.  Von  Graefe,  however,  mentions  a  case  in 
which  the  performance  of  an  early  ii'idectomy  exerted  a  beneficial 
influence  upon  the  course  of  the  inflammation.  He  employed  his  narrow 
cataract  knife,  and  made  the  incision  very  peripheral  (just,  in  fact,  as 
for  the  operation  for  cataract),  and  thus  succeeded  in  seizing  and 
excising  a  portion  of  iris.  He,  however,  strongly  advises  that  the 
iridectomy  should  be  made  as  early  as  possible,  as  soon,  in  fact,  as  the 
ominous  character  of  the  disease  manifests  itself.  But,  when  the  disease 
has  become  fully  established,  the  pupil  and  posterior  surface  of  the  iris 
being  tied  down  to  the  capsule  of  the  lens  by  firm  masses  of  exudation, 
and  the  tissue  of  the  iris  shows  symptoms  of  disorganization,  no  operation 
should  be  performed.  It  is  then  far  wiser  to  wait  until  the  active  in- 
flammatory symptoms  have  subsided.  Yon  Graefe  thinks  that  we  should 
wait  until  the  tenderness  of  the  ciliary  region  has  diminished,  the  de- 
velopment of  the  large  venous  trunks  in  the  disorganized  iris  become 
arrested  or  retrograded,  the  exudations  in  the  pupil  have  changed  their 
yellow  colour  for  a  more  bluish-grey  tint,  the  intra-ocular  tension 
(which  is  generally  distinctly  diminished)  shows  no  fluctuations,  and, 
finally,  until  at  least  three  or  four  months  have  elapsed  since  the  out- 
break of  the  disease.  In  opposition  to  this,  it  might  be  urged  that  if 
the  disease  is  thus  allowed  to  run  its  course  unchecked,  the  eye  might 
become  so  atrophied,  and  its  functions  so  much  impaired  as  to  be  beyond 
all  hope  of  improvement.  But,  in  such  malignant  cases,  any  operative 
interference  only  accelerates  this  result,  and  then,  again,  these  are, 
according  to  Yon  Graefe,  quite  exceptional  cases,  for  generally  the 
atrophy  of  the  eyeball  becomes  arrested  at  a  certain  point,  not  reaching 
perhaps  a  high  degree,  and  the  quantitative  perception  of  light  remains 
good.  Under  such  circumstances,  much  advantage  is  gained  by  waiting 
as  long  as  possible  with  the  operation,  because,  as  he  states,  "  the 
vascularisation  and  irritability  of  the  exiidation-masses  diminish  when 
the  acme  of  the  disease  is  passed,  and  besides,  the  extensive  operative 
interferences  which  will  have  to  be  undertaken  will  be  borne  much 
better;  whilst  at  an  earlier  period  haemoriliagic  efiusions  from  the 
delicate  and  newly  developed  vessels,  and  the  proliferation  of  the  neo- 
plastic formations  again  destroy  the  result  of  the  operation.  Moreover, 
the  whole  tendency  of  the  diSusion  of  the  traumatic  irritation  upon 


SYMPATHETIC  OPHTHALMIA.  205 

the  choroidal  tract  diminislaes  with  the  prolonged  existence  of  the 
disease  ;  and  not  nnfrequently  the  tension  of  the  eyeball  becomes  in- 
creased."* 

The  operation  which  should  be  performed  in  such  a  case  is  the 
removal  of  the  lens,  together  with  an  extensive  iridectomy  and  a  dila- 
ceration  of  the  masses  of  exudation.  This  may  be  performed  according 
to  Von  Graefe's  method,  described  at  page  193,  or  in  that  practised  by 
Bowman. 

The  mode  of  performing  the  operation  of  excision  of  the  eyeball  is 
described  in  the  chapter  on  "Diseases  of  the  Orbit." 

I  have  ah-eady  stated  that  the  sympathetic  ii-ritation  is  evidently 
propagated  by  the  ciHary  nerves,  and  this  fact  has  led  Yon  Graefe  to 
suggest  the  division  of  these  nerves  at  the  point  where  the  ciHary  region 
of  the  injured  eye  remains  sensitive  to  the  touch.  Dr.  Meyer,t  of 
Paris,  has  performed  this  operation  with  marked  success  in  several  cases 
of  sympathetic  neurosis.  After  having  raised  and  incised  the  conjunc- 
tival and  subconjunctival  tissue  over  the  painful  portion  of  the  ciliary 
region,  just  as  in  the  operation  for  strabismus,  he  introduces  a  squint 
hook  underneath  the  tendon  of  the  nearest  rectus  muscle,  so  that  the 
eye  may  be  well  steadied.  He  then  obHquely  punctures  the  sclerotic 
at  the  painful  point  of  the  ciliary  region  with  Von  Graefe's  narrow 
cataract  knife,  in  such  a  manner  that  the  wound  lies  parallel  to  the  edge 
of  the  cornea.  The  vitreous  humour  is  at  once  exposed  by  the  incision. 
The  hook  being  carefully  removed  the  conjunctival  wound  is  to  be 
closed  by  a  suture,  the  sclerotic  incision  heahng  in  the  course  of  a  few 
days. 

*  "  A.  f.  O.,"  xii,  2,  165. 
t  "  Aunales  d'Oculistique,"  Sept.,  1867,  p.  120. 


Chapter  IV. 

DISEASES    OF    THE    CILIARY    BODY   AND 
SCLEROTIC. 


INFLAMMATION  OF  THE  CILIARY  BODY  (CYCLITIS), 

ETC. 

The  congestion  and  hyperEemia  of  the  ciliary  body  wliicli  are  met 
with  in  cases  of  iritis  accompanied  by  extensive  posterior  synechiae, 
soon  give  rise  to  cyclitis,  the  inflammation  but  too  frequently  extending 
to  the  choroid.  Again,  the  reverse  may  obtain,  the  inflammation  may 
commence  in  the  choroid,  and  extend  thence  to  the  ciliary  body,  and 
perhaps  to  the  iris.  But  idiopathic  cyclitis  may  also  be  met  with,  more 
especially  after  injuries  to  the  ciliary  region,  such  as  contusions,  incised 
or  punctured  wounds,  or  the  lodgement  in  it  of  a  foreign  body.  The 
presence  of  cyclitis  is  in  such  cases  recognised  by  the  appearance  of 
very  marked  subconjunctival  injection,  acute,  often  indeed  intense  pain, 
on  pressure  of  the  ciliary  region,  great  ciliary  neuralgia,  and  the  ap- 
pearance of  hypopyon.  We  may  distinguish  two  principal  forms  of 
cyclitis,  the  serous  and  the  furuleid. 

Serous  cyclitis  often  supervenes  in  the  course  of  serous  iritis,  more 
especially  if  the  latter  is  severe  in  character,  and  has  been  negligently 
or  injudiciously  treated  with  astringent  or  caustic  collyria.  The  co- 
existence of  serous  cychtis  must  be  suspected,  if  together  with  the  symp- 
toms of  serous  iritis,  there  is  marked  pain  upon  pressure  of  the  ciliary 
region.  This  tenderness  is  very  frequently  situated  at  the  upper  or 
inner  portion  of  the  cihary  region.  Also,  if  the  tension  of  the  eyeball 
is  increased,  accompanied  by  dilatation  of  the  pupil  and  shallowness 
of  the  anterior  chamber ;  and  if  the  vitreous  becomes  diffusely  clouded, 
having  also  large  fixed  or  floating  opacities  suspended  in  it.  The  veins 
of  the  iris  are  likewise  often  dilated  and  tortuous.  There  is  at  the 
same  time  mai-ked  and  rapid  detei-ioration  of  the  sight,  which  is  in  part 
dependant  upon  the  opacity  of  the  vitreous  humour,  and  in  part  upon 
the  increase  of  the  eye  tension,  which  causes  compression  of  the  retina. 
The  accommodation  and  field  of  vision  are  also  more  or  less  impaired. 
The  supervention  of  cyclitis  in  cases  of  serous  iritis  is  always  to  be 


INFLAMMATION   OF   THE   CILIARY   BODY   (CYCLITIS).  207 

regarded  witli  apprehension,  and  the  state  of  the  sight,  of  the  field  of 
vision,  and  of  the  tension  of  the  eye,  should  be  watched  with  great 
anxiety,  for  if  the  symptoms  do  not  yield  to  the  usual  remedies,  but 
rather  increase  in  severity,  no  time  should  be  lost  in  performing  iridec- 
tomy. Still  graver  is  the  danger  inpuruJent  ci/clitis,  which  is  characterised 
by  the  following  symptoms  : — There  is  very  marked  subconjunctival 
injection,  together  with  great  ciliary  neuralgia,  photophobia,  and  lachry- 
mation.  The  colour  of  the  iris  is  somewhat  changed,  and  if  there  is 
considerable  iritis  it  may  be  greatly  altered.  The  veins  of  the  iris  are 
dilated.  This,  indeed,  is  a  very  pathognomonic  symptom  of  cyclitis,  and 
it  is  due  to  the  following  cause : — On  account  of  the  inflammatory  changes 
in  the  ciliary  body  the  venous  efflux  from  the  iris  is  more  or  less  im- 
peded, and  the  blood  does  not  readily  flow  ofi"  from  the  veinlets  of  the 
iris,  whiih,  therefore,  become  dilated  and  engorged.  The  region  of  the 
ciliary  body  is  very  tender  to  the  touch,  sometimes  the  pain  thus  pro- 
duced is  so  exquisitely  acute  that  the  patient  shrinks  back  with  appre- 
hension. Pus  makes  its  appearance  in  the  anterior  chamber,  and  sinks 
down  to  the  bottom  in  the  form  of  a  more  or  less  extensive  hypopyon.  It 
should  be  remembered  that  an  hypopyon  may  be  due  to  a  purulent  exu- 
dation from  the  ciliary  body ;  for  at  the  rim  of  the  anterior  chamber  the 
ciliary  body  is  only  separated  from  the  latter  by  the  delicate  division  of 
the  membrane  of  Descemet,  through  which  pus  may  easily  exude  into 
the  anterior  chamber,  and  then  become  precipitated  in  the  form  of 
hypopyon.  If  we  can,  therefore,  exclude  the  origin  of  the  latter  from 
the  cornea  and  iris,  we  may  be  certain,  even  apart  from  other  symptoms, 
that  it  is  due  to  cychtis.  The  edge  of  the  pupil  is  often  adherent,  its 
area  blocked  up  with  a  dense  plug  of  lymph,  and  a  purulent  exudation 
is  but  too  frequently  poured  out  behind  the  iris,  and  also  perhaps  into 
the  vitreous  humour. 

Purulent  cyclitis  is  very  apt  to  occur  after  injuries  to  the  ciliary 
body,  operations  for  cataract,  and  as  sympathetic  ophthalmia,  indeed  it 
is,  as  we  have  seen,  the  form  under  which  the  latter  most  frequently 
makes  its  appearance. 

At  the  commencement,  the  constant  application  of  hot  poppy  fomen- 
tations frequently  afibrd  very  marked  relief  to  the  severe  ciUary  neu- 
ralgia, and  sensitiveness  of  the  ciliary  region.  If  this  is  not  the  case, 
and  if  there  is  great  hypereemia  and  congestion  of  the  subconjunctival 
vessels,  as  also  of  those  of  the  iris,  leeches  should  be  applied,  and  when 
they  have  drawn  very  freely,  a  strong  solution  of  atropine  should  be 
employed,  in  order  to  produce  dilatation  of  the  pupil  as  soon  as  possible. 
If  there  is  much  nocturnal  pain,  or  the  patient  is  i-estless,  a  subcutane- 
ous injection  of  morphia  is  indicated.  When  a  considerable  exudation 
of  lymph  occurs  into  the  anterior  chamber,  or  into  the  vitreous  humour, 
salivation  should  be  induced  as  rapidly  as  possible  by  the  inunction  of 


208  DISEASES   OF   THE   CILIARY   BODY  AND   SCLEROTIC. 

the  mercurial  ointment.  It  must  be  confessed,  however,  that  we  are 
often  quite  unable  to  stay  the  progress  of  the  disease,  and  prevent  the 
loss  of  the  eye  from  suppurative  irido-cyclitis,  terminating  in  atrophy 
of  the  globe. 

An  extensive  iridectomy,  if  performed  at  an  early  stage  of  the  disease, 
often  exerts  a  very  beneficial  influence  upon  the  course  of  the  latter.  At 
a  later  period  it  is  but  too  frequently  followed  by  a  recurrence  of  severe 
inflammation,  with  a  fresh  exudation  of  pus,  which  completely  blocks 
up  the  artificial  pupil. 

Injuries  •implicating  the  ciliary  region  are  not  only  dangerous  on 
account  of  the  inflammatory  complications  to  which  they  may  give  rise 
in  the  injured  eye,  but  also  on  account  of  the  risk  of  sympathetic 
ophthalmia,  which  they  are  very  prone  to  excite.  Simple  incised  wounds 
of  the  sclerotic  at  or  near  the  edge  of  the  cornea,  if  they  are  not  exten- 
sive in  size,  and  have  not  penetrated  too  deeply,  and  thus  caused  severe 
injuiy  to  the  ciliary  body,  lens,  etc.,  will  often  rapidly  unite,  on  the 
insertion  of  a  fine  suture.  Such  wounds  may  be  produced  by  frag- 
ments of  glass  or  steel,  or  by  a  clean  ciit  from  a  small  sharp  instrument. 
In  the  former  case,  a  careful  examination  should  always  be  made  as  to 
the  presence  of  the  foreign  body,  which  may  either  have  fallen  out  after 
having  wounded  the  sclerotic,  have  entered  the  eyeball,  or  be  lying  in 
the  lips  of  the  wound,  whence  it  may  be  readily  extracted.  A  bead  of 
vitreous  is  seen  protruding  between  the  hps  of  the  little  wound,  and  this 
constant  oozing  greatly  diminishes  the  intra- ocular  tension,  the  eye  being 
generally  extremely  soft.  But  whilst  the  tension  in  the  vitreous  humour 
is  much  diminished,  that  in  the  anterior  chamber  may  be  augmented, 
the  iris  being  cupped  backwards,  and  the  depth  of  the  anterior  chamber 
much  increased,  and  being  occupied  by  yellowish  serum.  This  causes  a 
peculiar  and  markedly  greenish  discoloration  of  the  iris,  more  especially 
if  the  latter  is  normally  of  a  blue  or  bluish-grey  tint.  In  such  cases, 
by  far  the  best  treatment  consists  in  bringing  the  lips  of  the  little 
scleral  v.'ound  together  with  a  fine  suture.  This  is  best  and  most  safely 
done  by  attaching  a  curved  needle  to  each  end  of  a  very  fine  silk  thread, 
and  passing  one  needle  through  the  one  edge  of  the  wound  from  within 
outwards,  and  the  other  needle  through  the  opposite  edge  also  from 
within  outwards.  In  this  way  we  shall  avoid  all  danger  of  injuring 
the  ciliary  body  or  lens  from  a  sudden  jerk  of  the  point  of  the  needle 
deeply  into  the  eye.  The  sutiu-e  generally  produces  little  or  no  irrita- 
tion, and  may  be  left  for  eight  or  ten  days,  until  the  wound  is  firmly 
united.  As  soon  as  the  oozing  of  the  vitreous  is  arrested  the  intra- 
ocular tension  increases,  and  in  the  course  of  a  day  or  two  it  generally 
reaches  the  normal  standard.  If  the  depth  of  the  anterior  chamber  is 
much  increased  by  the  accumulation  of  serum,  an  iridectomy  should 


DISEASES   OF   THE   SCLEROTIC.  209 

be  made   to  re-establish  the  commvinication  between  the  anterior  and 
posterior  chambers. 

A  description  of  the  tumours  met  with  in  the  ciliary  region  will  be 
found  in  the  article  upon  "  Tumours  of  the  Choroid." 


DISEASES  OF  THE  SCLEEOTIC. 

1.— EPISCLERITIS. 

Though  not  a  dangerous  affection,  episcleritis  often  proves  extremely 
troublesome  on  account  of  the  protracted  and  obstinate  covirse  which  it 
runs,  and  also  on  account  of  the  tendency  to  frequent  recurrence  which 
it  often  manifests.  It  is  distinguished  by  the  appearance  of  a  small 
dusky-red,  or  reddish-yellow  elevation  on  the  sclerotic,  in  close  proximity 
to  the  insertion  of  one  of  the  recti  muscles,  and  at  a  short  distance 
from  the  edge  of  the  cornea.  It  occurs  most  frequently  at  the  tem- 
poral portion  of  the  sclerotic,  near  the  insertion  of  the  external  rectus 
muscle.  The  appearance  of  the  little  nodule  is  generally  preceded  and 
accompanied  by  more  or  less  conjunctival  and  subconjunctival  redness, 
more  especially  of  that  segment  of  the  eyeball  upon  which  the  elevation 
is  situated,  to  which,  indeed,  the  vascularity  is  often  confined.  The 
subconjunctival  tissue  is  at  this  point  markedly  thickened  and  swollen, 
and  of  a  peculiar  rusty,  dark,  purplish  hue,  its  blood-vessels  (as  well, 
perhaps,  as  those  of  the  conjunctiva)  being  here  somewhat  dilated, 
tortuous,  and  of  a  dusky  tint.  Frequently  the  conjunctiva  is  hardly 
at  all  affected,  the  vascularity  and  swelhng  being  confined  to  the  sub- 
conjunctival tissue  and  the  superficial  layers  of  the  sclerotic.  There  is 
sometimes  considerable  photophobia,  lachrymation,  and  a  certain  degree 
of  ciliary  neui-algia,  but  in  many  cases  these  symptoms  are  almost  entrrely 
absent,  and  the  patient  experiences  only  slight  discomfort,  or  a  feeling 
of  dull,  heavy  pain  in  and  around  the  eye.  The  affected  point  of  the 
sclerotic  may  also  be  more  or  less  sensitive  to  the  touch.  At  the  outset, 
the  affection  might  be  mistaken  for  phlyctenular  or  pustular  ophthalmia, 
but  the  little  nodule  soon  increases  in  size,  and  assumes  a  dusky,  reddish- 
brown  appearance,  having  a  broad  base,  and  showing  no  tendency  to 
ulcerate  or  suppurate.  Gradually  it  becomes  more  pale,  diminishes  in 
size,  and  slowly  disappears,  after  it  has  existed  perhaps  for  many  months. 
Or  it  may  recur  again  and  again,  either  at  the  same  spot,  or  at  some 
other  point  of  the  eyeball,  so  that  the  disease  may  travel  round  the 
cornea  from  point  to  point. 

The  disease  is  not  only  veiy  protracted  and  obstinate  in  its  course, 
but  also  very  little  influenced  either  by  general  or  local  treatment.     It 

p 


210  DISEASES  OF   THE   CILIARY  BODY   AND   SCLEROTIC. 

occurs  most  frequently  in  females  of  an  adult  age,  and  does  not  appear 
to  be  due  to  any  appreciable  cause,  except  tliat  it  is  perhaps  more 
often  met  with  in  persons  of  a  rheumatic  tendency  than  in  others. 
The  cornea  sometimes  becomes  implicated,  more  especially  the  part 
nearest  the  elevation,  the  superficial  portions  of  the  cornea  becomiiig 
cloudy,  and  this  opacity  assuming  somewhat  the  appearance  of  a  partial 
arcus  senilis.  If  there  is  much  ciliary  irritation  and  pain,  atropine 
drops  should  be  employed,  and  warm  poppy  fomentations  be  applied  to 
the  eye.  The  insufflation  of  calomel  or  the  ase  of  the  red-precipitate 
ointment  have  proved  of  little  benefit  in  my  hands ;  indeed,  I  think 
them  contra-indicated  if  there  is  any  c  iliary  irri .  ation,  still  more  so  is 
this  the  case  with  caustic  collyria.  I  have,  however,  in  some  cases  found 
marked  and  striking  benefit  from  the  use  of  a  collyrium  of  chloride  of 
zinc.  I  employ  at  first  a  very  weak  solution  (gr.  ^  to  ^j  of  water),  and 
if  this  is  well  borne  and  does  not  augment  the  redness  or  produce  much 
irritation,  I  increase  the  strength  to  gr.  i— ii  to  ^j-  The  patient  should 
be  placed  upon  a  generous  diet,  and  tonics  should  be  freely  ad- 
ministered. 


2.— ANTERIOR  SCLEROTIC  STAPHYLOMA. 

Staphylomatous  bulging  of  the  sclerotic  may  be  chiefly  or  entirely 
confined  to  one  part  of  the  anterior  portion  of  the  sclerotic,  or  it  may 
involve,  more  or  less,  the  whole  of  the  eyeball. 

The  partial  anterior  staphyloma  is  generally  situated  near  the  cihary 
region,  or  further  back  near  the  equator  of  the  eye.  It  may  occur  at 
any  point  from  the  edge  of  the  cornea  to  the  equatorial  region  of  the 
eyeball,  and  frequently  shows  itself  between  the  insertion  of  two  of  the 
recti  muscles,  as  there  is  less  resistance  offered  at  such  a  point  to  the 
protrusion  of  the  sclerotic. 

In  the  great  majority  of  cases  staphyloma  of  the  sclerotic  is  due 
to  irido-choroiditis,  accompanied  by  an  increase  in  the  intra-ocular 
tension,  which  leads  to  distension  and  bulging  of  the  sclerotic  at  one  or 
more  points,  the  resistance  of  the  sclerotic  having  moreover  been  per- 
haps also  weakened  by  an  inflammatory  thinning  of  its  structure.  The 
prominence  of  the  inflammatory  symptoms  varies  very  greatly  according 
to  the  rapidity  and  acuteness  with  which  the  staphyloma  is  formed.  If 
tlio  course  of  the  disease  is  very  acute,  we  find  that  there  are  marked 
symptoms  of  irido-choi-oiditis.  There  is  conjunctival  and  subconjunc- 
tival injection,  accompanied  perhaps  by  a  certain  degree  of  chemosis, 
more  especially  over  and  around  that  part  of  the  sclerotic  which  is 
beginning  to  bulge.  The  ciliary  neuj^algia  is  often  very  severe,  and  the 
ciliary  region  acutely  sensitive  to  the  touch.     The  edge  of  the  cornea 


i 


ANTERIOR   SCLEROTIC   STAPHYLOMA.  211 

may  be  somewhat  opaqne,  the  aqueous  humour  hazy,  the  iris  discoloured 
and  inflamed,  and  its  pupillary  edge  tied  down  by  exudations  of  lymph. 
If  the  pupil  is  sufficiently  clear  to  admit  of  an  ophthalmoscopic 
exam.ination,  the  vitreous  humour  is  often  found  diflfusely  clouded,'  with 
large,  dark  shreds  floating  about  in  it.  The  tension  of  the  eye  is 
generally  considerably  increased,  and  the  sight  and  field  of  vision 
greatly  impaired.  The  increase  in  the  eye-tension  is  not,  howevei', 
absolutely  necessary  to  the  production  of  a  staphyloma.  For  on  account 
of  an  inflammatory  thinning  of  a  certain  portion  of  the  sclei'otic,  the 
latter  may  not  be  sufficiently  firm  and  strong  at  this  point  to  resist  the 
presence  of  even  a  normal  degree  of  intra-ocular  tension,  and  conse- 
quently yields  before  it.  In  such  a  case  there  would  of  course  be  no 
augmentation  of  the  eye-tension,  no  hardness  of  the  globe.  Such  cases 
are,  however,  rare  in  comparison  to  the  others,  in  which  the  increase  of 
the  tension  is  the  chief  cause  of  the  protrusion.  Besides  the  severe 
pain,  the  patient  often  complains  of  bright  flashes  of  light  (photopsics). 
Soon  there  is  noticed  at  one  point  of  the  sclerotic  a  slight  prominence 
or  bulging,  the  outline  of  which  may  be  circumscribed  and  clearly 
defined,  or  be  irregular  and  pass  gradually  and  insensibly  over  into  the 
healthy  sclerotic.  As  the  bulge  increases,  the  sclerotic  becomes  more 
and  more  thinned  (partly  perhaps  from  inflammation  and  partly  from 
distension)  and  discoloured,  assuming  at  this  point  a  dusky,  dirty, 
bluish- grey  hue,  which  is  due  to  the  shining  through  of  the  choroid. 
Thus  the  staphyloma  may  attain  a  considerable  size  even  in  the  course  of 
a  few  weeks.  Together  with  the  increase  in  the  size  of  the  staphyloma, 
the  proximate  portion  of  the  ciliary  region  and  even  of  the  cornea  may 
become  involved  in  it,  and  be  considerably  changed  in  curvature,  the 
corresponding  plane  of  the  iris  and  the  zonula  of  Zinn  being  stretched, 
and  the  attachment  of  the  lens  consequently  relaxed  and  loosened. 

As  a  rule,  however,  the  progress  of  the  staphyloma  is  very  slow  and 
gradual.  After  a  more  or  less  acute  and  severe  inflammation  of  the 
iris  and  choroid  has  existed  for  some  length  of  time,  and  its  progress 
has  been  perhaps  apparently  arrested,  it  is  noticed  that  the  curvature 
of  one  portion  of  the  sclerotic  is  somewhat  altered  and  more  prominent, 
and  its  surface  traversed  by  dark,  dilated  vessels.  Gradually  and 
slowly  the  protrusion  increases,  the  sclerotic  becomes  more  thinned, 
and  exchanges  its  bright  lustrous  white  colour  for  a  dusky  bluish  tint. 
Sometimes  the  staphylomatous  bulging  is  traversed  by  tendinous 
glistening  trabeculse,  forming  a  kind  of  framework,  through  the  inter- 
stices of  which  the  darker  portions  bulge  out,  giving  to  the  whole  a 
faint  likeness  to  a  mulberry.  The  staphyloma  may  now  remain  sta- 
tionary for  a  time,  and  the  inflammatory  symptoms  disappear.  Then 
an  inflammatory  exacerbation  supervenes,  the  eye  becomes  painful, 
irritable,   flushed,    and    an    increase    in  the 'size  of  the  staphyloma  is 

p  2 


212  DISEASES  OF   THE   CILIARY  BODY   AND   SCLEROTIC. 

noticed.  Bat  these  symptoms  again  disappear,  and  the  progress  of  the 
disease  is  temporarily  arrested.  Such  exacerbations  may  be  of  fre- 
quent occurrence,  and  lead,  finally,  to  a  considerable  and  very  pro- 
minent staphyloma.  Sometimes  the  staphylomatous  bulgings  are  not 
chiefly  confined  to  one  portion  of  the  sclerotic,  but  occupy  the  whole  of 
the  ciliary  region  around  the  cornea,  and  then  the  disease  is  termed 
"  annular  staphyloma." 

The  distension  and  bulging  is  not  limited  to  the  sclerotic,  but 
extends  to  the  choroid,  which  is  generally  adherent  to  the  former,  and 
consequently  stretched  and  bulged  with  it,  undergoing  in  time  perhaps 
almost  complete  atrophy.  The  retina  may  either  be  adherent  to  the 
choroid,  and  therefore  also  stretched  and  altered  in  structure,  or  it  may 
be  separated  from  it  at  this  point,  and  pass  straight  across  the  base  of 
the  staphylomatous  bulge,  the  cavity  of  the  latter  being  occupied  by  a 
serous  fluid.  The  vitreous  humour  is  also  more  or  less  clouded  and 
fluid.  Sometimes  it  is  however  quite  transparent,  and  we  can  then 
distinctly  see  (if  the  other  refractive  media  are  clear)  the  details  of  the 
fundus,  and  perhaps  detect  a  deep  excavation  of  the  optic  nerve. 
Generally,  however,  we  are  unable  to  see  the  fundus  on  account  of 
exudations  in  the  pupil,  or  the  opacity  of  the  lens  and  vitreous  humour. 

In  complete  sclerotic  staphyloma  the  anterior  portion  of  the  sclerotic 
and  the  cornea  are  greatly  altered  in  curvature,  being  either  distended 
into  a  conical,  or  sub-ovoid  shape.  The  iris  and  zonula  of  Zinn  are  also 
much  distended.  The  plane  of  the  iris  is  greatly  increased  in  size  and 
discoloured,  being  of  a  dirty  slate  tint,  which  is  partly  owing  to 
inflammatory  changes,  and  partly  to  the  stretching  and  atrophy  of  its 
fibrillse.  It  is,  moreover,  often  tremulous  on  account  of  the  partial  or 
com.plete  dislocation  of  the  lens,  or  on  account  of  the  latter  being 
separated  from  its  posterior  surface  by  a  considerable  amount  of  fluid. 
From  the  distension  and  stretching  of  the  zonula  of  Zinn,  the  attach- 
ments of  the  lens  are  relaxed  and  weakened,  and  the  latter  may  be 
partially  or  completely  dislocated  into  the  vitreous  humour.  The 
depth  and  size  of  the  anterior  chamber  are  often  greatly  increased. 
Indeed  the  whole  eye  is  much  enlarged,  and  on  this  account  as  well 
as  the  protrusion  of  the  eye  from  the  orbit,  this  condition  is  often 
termed  "  buphthalmos."  The  sclerotic  is  traversed  by  dilated  tortuous 
vessels,  and  is  of  a  dusky,  dark-blue  tint,  which  is  either  diffuse  and 
uniform  in  character,  or  chiefly  confined  to  certain  points,  giving  to  the 
whole  a  dark,  patchy  appearance.  The  pupil  is  often  occupied  by 
lymph,  the  capsule  of  the  lens  opaque,  and  covered  by  masses  of 
exudation,  the  lens  itself  being  also  frequently  cataractous.  If  the 
staphyloma  has  formed  after  an  extensive  perforation  of  the  cornea, 
there  will  be  no  anterior  chamber,  the  iris  and  capsule  of  the  lens  are 
intimately  connected  with  and  adherent  to  the  corneal  cicatrix,  the  lens 


WOUNDS   AND   INJURIES   OF   THE   SCLEROTIC.  213 

is  cataractous,   perliaps    shrivelled    and    chalky,  or  altogether  absent, 
having  escaped  through  the  corneal  perforation. 

Both  the  partial  and  complete  staphyloma  may  after  a  time  become 
arrested,  the  inflammatory  exacerbations  become  less  and  less  frequent, 
and  finally  cease.  In  other  cases,  severe  suppurative  irido-choroiditis 
supervenes,  and  gradually  leads  to  atrophy  of  the  eye.  Or  again,  the 
bulging  portion  in  a  partial  staphyloma  may  give  way,  either  spon- 
taneously or  in  consequence  of  a  blow  upon  the  eye,  or  a  sudden  and 
severe  strain  or  exertion.  A  great  portion  of  the  contents  of  the  eyeball 
escapes,  this  being  often  accompanied  by  profuse  intra-ocular  haemorr- 
hage ;  severe  inflammation  supervenes,  and  the  globe  shrinks  and 
atrophies. 

With  regard  to  the  treatment,  I  need  only  say  that  at  the  very 
outset  of  the  disease,  when  the  symptoms  are  only  those  of  irido-choroi- 
ditis the  usual  remedies — atropine,  leeches,  paracentesis,  etc. — should  be 
employed,  but  when  the  tension  of  the  eye  is  markedly  increased,  and  if 
the  sclerotic  shows  at  one  point  a  tendency  to  bulge,  these  remedies  no 
longer  suffice,  and  a  large  iridectomy  should  be  made  at  once.  If  this 
should  not  check  the  inflammation  and  the  bulging  of  the  sclerotic, 
repeated  paracentesis  may  be  tried,  or  a  second  iindectomy  may  be  made 
opposite  to  the  first,  so  as  to  divide  the  iris  into  two  separate  halves. 
But  if  the  staphyloma  is  considerable  and  has  existed  for  some  time,  the 
iridectomy  no  longer  suffices  to  cause  it  to  shrink,  and  we  may  then 
have  to  abscise  it.  This  should  be  done  with  a  cataract  knife,  as  in  the 
case  of  staphyloma  of  the  cornea  (page  136).  After  the  operation 
a  firm  compress  bandage  is  to  be  applied.  In  cases  of  partial  staphy- 
loma, more  especially  if  the  base  is  small,  I  should  prefer  Borelli's 
operation  (page  140)  to  abscission.  In  those  cases  in  which  the  sight 
is  greatly  and  hopelessly  lost,  and  the  eye  is  a  source  of  constant  irrita- 
tion and  discomfort,  abscission  by  Critchett's  method  should  be  per- 
formed. But  if  the  disease  reaches  far  back,  or  involves  the  whole 
eyeball,  it  will  be  much  wiser  to  excise  the  eye,  for  by  abscising  the 
anterior  part,  a  portion  of  the  diseased  structures  will  be  left  behind, 
and  the  stump  be  prone  to  inflammatory  complications,  and  thus  prevent 
perhaps  the  possibility  of  wearing  an  artificial  eye  with  comfort,  and 
even  endanger  the  safety  of  the  other  eye. 


3.— WOUNDS  AND  INJURIES  OF  THE  SCLEROTIC. 

Incised  wounds  of  the  sclerotic  chiefly  prove  dangerous  in  so  far 
that  if  they  are  extensive,  a  considerable  portion  of  the  contents  of  the 
eyeball  escapes,  which  is  perhaps  followed  by  profuse  intra-ocular 
haemorrhage,  suppurative  choroiditis,  and  finally  atrophy  of  the  eyeball. 


214  DISEASES   OF   THE   CILIARY   BODY   AND   SCLEROTIC. 

Or  again,  if  the  wound  is  smaller,  its  cicatrization  may,  by  involving  a 
portion  of  the  retina,  lead  to  a  detachment  of  the  latter,  which,  though 
limited  at. first,  may  gradually  extend  and  threaten  the  safety  of  the  eye. 
Again,  the  instrument  producing  the  injury  may  wound  the  lens  and 
cause  traumatic  cataract,  accompanied  perhaps  by  severe  inflammatory 
complications  leading  to  the  destruction  of  the  sight.  Still  greater  is 
the  danger  if  the  point  of  the  instrument  is  broken  off  and  lodged  in  the 
interior  of  the  eye,  the  same  being  the  case  if  foreign  bodies  have  per- 
forated the  sclerotic  and  entered  the  globe.  If  the  wound  is  situated  at 
the  anterior  portion  of  the  sclerotic  near  the  cornea,  the  iris  generally 
protrudes,  and  the  lens  may  be  dislocated  under  the  conjunctiva ;  this 
is  especially  the  case  after  severe  blows  from  blunt  instruments,  pro- 
ducing a  rupture  of  the  sclerotic.  Indeed,  ruptures  of  the  sclerotic  are 
generally  far  more  dangerous  than  incised  wounds,  on  account  of  the 
gi'eat  force  of  the  blow  which  was  necessary  to  cause  the  sclerotic  to 
give  way.  If  the  incised  wound  is  not  considerable  in  size,  its  edges 
should  be  carefully  brought  together  by  a  fine  suture  or  two.  Any 
portion  of  protruding  ms  or  vitreous  humoui*  being  abscised,  cold  com- 
presses should  then  be  applied  to  allay  the  inflammatory  reaction.  In 
small  punctured  wounds  a  little  bead  of  vitreous  may  protrude  through 
the  little  aperture,  and  if  the  application  of  a  firm  compress  does  not 
accelerate  union,  the  object  may  be  obtained  by  lightly  touching  the 
wound  with  a  crayon  of  nitrate  of  silver  and  potash  every  second  or 
third  day.  When  the  wound  is  very  extensive  and  a  large  portion  of 
the  contents  of  the  globe  has  escaped,  and  there  is  no  hope  of  restoring 
any  sight,  it  is  better  to  excise  the  eyeball  at  once,  more  especially  if  it 
is  to  the  patient  a  matter  of  great  moment  (as  amongst  the  poorer 
classes)  to  be  cured  as  soon  as  possible,  and  to  be  free  from  further 
inflammatory  attacks. 

A  portion  of  the  sclerotic  may  slough  after  injuries  from  burns,  hot 
metal,  etc.  The  injured  part  becomes  covered  with  a  whitish  grey 
eschar,  which  is  thrown  off  together  with  portions  of  the  sclerotic,  until 
the  vitreous  humour  becomes  visible.  The  injury  may  be  accompanied 
by  inflammation  of  the  cornea  and  iris,  and  opacity  of  the  lens. 


Chapter  V. 
DISEASES   OF   THE   CRYSTALLINE   LENS. 


1.— CATARACT. 


By  tlie  general  term  "cataract"  is  understood  an  opacity  situated 
in  the  crystalline  lens  :  to  such  only  should  it  be  applied.  When  the 
opacity  is  in  the  capsule,  it  is  termed  "  capsular  cataract ;"  whereas, 
when  both  the  capsule  and  lens  are  involved,  it  is  designated  "  capsulo- 
lenticular  cataract."  The  "spurious  cataract  "  of  old  authors,  which 
was  the  name  given  to  deposits  of  lymph  in  the  pupil,  should  be 
altogether  abolished. 

It  must  be  frankly  admitted  that  the  etiology  of  cataract  is  still 
shrouded  in  much  obscui-ity  and  doubt.  It  appears  most  probable  that 
the  principal  causes  of  the  loss  of  transparency  of  the  lens  are  to  be 
sought  in  an  impairment  of  its  nutrition,  and  in  inflammatory  changes 
within  the  lens  itself.  The  defect  in  the  nutrition  may  be  due  to  certain 
alterations  in  the  condition  of  the  blood,  to  senile  involution,  or  to 
inflammatory  lesions  of  the  neighbouring  tunics  (e.r/.,  irido-choroiditis, 
sclerotico-choroiditis  posterior,  retinitis  pigmentosa,  etc.).  Cataract  is 
not  unfrequently  met  with  in  those  conditions  of  the  blood  in  which  its 
watery  constituents  are  very  deficient,  so  that  it  assumes  great  density 
(as,  for  instance,  in  diabetes).  This  gives  rise  to  an  exosmosis  of  the 
wateiy  constituents  of  the  lens,  a  loss  of  transparency  in  its  fibres,  and 
a  deposit  of  calcareous  and  other  salts.  In  diabetes,  the  cataract  does 
not  generally  appear  until  a  late  stage  of  the  disease,  when  the  patient 
is  greatly  emaciated  and  enfeebled,  and  his  health  much  broken.  I  have, 
however,  met  with  some  cases  in  which  the  opacity  of  the  lens  appeared 
whilst  the  general  health  was  still  good.  The  diabetic  cataract  is 
generally  met  with  about  or  before  middle  age,  and  does  not  present 
any  peculiar  or  characteristic  symptoms.  It  generally  affects  both 
eyes,  and  is  mostly  of  a  softish  consistence,  and  rapid  in  its  forma- 
tion. In  elderly  persons,  however,  it  will  be  more  firm,  and  contain 
a  more  or  less  large  hard  nucleus.  The  perception  of  light,  and 
the  condition   of  the  field  of  vision  should  always  be   very  carefully 


216  DISEASES  OF   THE   CRYSTALLINE  LENS. 

examined  m  sucli  cases,  as  affections  of  tlie  retina  and  optic  nerve  not 
unfrequently  occur  in  the  course  of  diabetes,  and  may,  therefore, 
co-exist  with  the  cataract,  and  thus  render  the  prognosis  of  the  opera- 
tion unfaroui^able.  Another  fact  which  shou.ld  be  remembered  in 
operating  for  diabetic  cataract  is,  that  the  iris  is  often  very  susceptible 
of  irritation,  so  that  iritis  is  exceptionally  easily  to  set  up.  The  ambly- 
opia which  is  sometimes  met  with  in  persons  affected  with  diabetes 
may,  however,  be  simply  due  to  paralysis  of  the  accommodation. 

The  presence  of  secale  cornutum  in  the  system  may  produce 
cataract.  Thus,  Dr.  Ignaz  Meyer*  has  shown  that  the  consumption  of 
bread  containing  ergot  of  rye  may  give  rise  to  it.  The  ergotism  has 
lasted  in  some  of  these  cases  for  two  or  thi'ee  months,  the  principal 
symptom  being  the  fits.  The  development  of  the  cataract  was  very 
slow,  and  always  occurred  in  both  eyes.  The  naode  in  which  the  ergo- 
tism gives  rise  to  cataract  is  still  very  uncertain,  bu.t  it  is  probably  due 
to  some  impairment  of  the  nutrition  of  the  lens.  Wecker  thinks  that 
this  mal-nutrition  may,  perhaps,  be  owing  to  a  diminution  in  the  blood 
supply  to  the  anterior  portion  of  the  uveal  tract,  on  account  of  the  pro- 
longed spasmodic  contraction  of  the  ciliary  muscle. 

Cataract  is,  as  a  rule,  a  disease  of  old  age,  and  the  loss  of  trans- 
parency of  the  lens  is  probably  chiefly  due  to  its  deficient  nutrition, 
dependent  upon  an  inefiicient  blood  supply,  and  consequent  diminution 
of  the  watery  constituents  of  the  crystalline.  We  must  not,  however, 
mistake  for  this  condition,  the  small  punctated  opacities  which  are  due 
to  senile  fatty  degeneration  of  the  fibrillse  of  the  lens,  and  which  some- 
times appear  in  old  persons  in  the  form  of  a  fringe  of  small,  yellowish, 
grey  dots,  situated  quite  at  the  periphery  of  the  lens,  where  they  may 
remain  stationary  for  a  very  long  period. 

Inflammations  of  the  inner  tunics  of  the  eye,  more  especially  of  the 
iris,  choroid,  and  vitreous  humour,  may  give  rise  to  cataract,  not  only 
by  an  impairment  of  the  nutrition  of  the  lens,  but  also  by  the  inflamma- 
tory changes  implicating  the  intra-capsular  cells,  and  even  the  lens 
itself.  Again,  the  cataract  may  be  due  to  the  presence  of  extensive 
deposits  of  lymph  upon  the  capsule,  which  prevent  the  osmotic  inter- 
change of  material  between  the  lens  and  aqueous  humour.  If  these 
exudations  cover  the  greater  portion  of  the  anterior  capsule,  the  opacity 
of  the  lens  generally  soon  becomes  complete,  whereas,  if  the  exudation 
is  confined  to  the  area  of  the  pupil,  the  cataract  is  often  only  partial. 
In  the  former  case,  the  watery  constituents  of  the  lens  soon  become 
absorbed,  the  lens  becomes  diminished  in  size  and  shrivelled  up,  and 
may  in  time  become  almost  entirely  absorbed,  there  being  only  an 
opaque,  white,  chalky  disc  left  behind. 

Cataract  is  very  frequently  due  to  some  injury  to  the  lens,  but  this 
*  "  A.  f.  O.,"  viii,  2,  120. 


CATARACT.  217 

form  will  be  considered  more  at  length  under  the  head  of  "  traumatic 
cataract." 

Considerable  difficulty  is  experienced  in  attempting  to  classify  the 
principal  forms  of  cataract  in  such  a  manner  that  then*  distinctive 
features  shall  be  easily  recognised  and  remembered.  Not  only  are  the 
minor  varieties  numerous,  but  some  of  them  do  not  present  any  marked 
characteristics,  so  that  theii*  description  often  proves  somewhat  confusing 
and  unintelligible  to  the  novice. 

I  think  it  most  practical  to  divide  lenticular  cataracts  into  two  prin- 
cipal classes  : — 1.  The  cortical,  or  soft  cataract ;  2.  The  nuclear,  or 
hard  cataract.  The  former  is  the  most  frequent  kind  of  congenital 
cataract,  and  is  met  with  in  various  forms  up  to  the  age  of  30  or  35, 
and  is  chiefly  characterised  by  the  fact,  that  although  the  whole  lens 
may  be  involved  in  the  process,  there  is  no  hard  nucleus.  The  nuclear 
cataract  occurs  generally  after  the  age  of  35  or  40,  and  is  distinguished 
by  the  presence  of  a  more  or  less  large,  yellow,  hard  nucleus.  I  am 
well  aware  that  so  general  a  division  is  open  to  the  objection  that  excep- 
tional cases  are  not  unfrequently  met  with,  so  that  all  varieties  cannot 
be  embraced  within  it.  Yet  "in  a  practical  point  of  view  I  believe  it  to 
be  the  best,  as  it  enables  us  to  lay  down  broad  rules  as  to  the  modes  of 
operation  to  be  selected.  For  instance,  the  cortical  cataract  m.ay  be 
operated  upon  by  division  with  the  needle,  by  suction,  or  by  linear 
extraction ;  whereas  the  nuclear  cataract,  on  account  of  the  presence  of 
a  hard  nucleus,  demands  extraction  either  through  a  corneal  or  scleral 
flap,  or  by  the  assistance  of  some  form  of  traction  instrument. 

But  there  is  one  form  of  soft  cataract  which  requires  a  special  descrip- 
tion, as,  on  account  of  its  peculiar  structure,  it  may  often  be  best  treated 
by  an  operation  which  does  not  interfere  with  the  lens  itself.  I  mean 
the  lamellar  or  zonular  cataract.  Cataracts  produced  by  injuries  to  the 
lens,  and  opacities  in  the  capsule,  will  be  considered  under  the  heads  of 
"  Traumatic  Cataract,"  and  "  Capsular  Cataract." 

Formerly,  much  attention  was  paid  to  the  symptoms  which  distin- 
guished cataract  from  glaucoma  and  amaurosis.  But  since  the  dis- 
covery of  the  ophthalmoscope,  these  diseases  could  not  be  mistaken  for 
cataract,  except  through  the  grossest  ignorance  or  carelessness. 

A  fully  formed,  mature  cataract  may  be  at  once  recognised  even 
with  the  naked  eye.  The  pupil  is  no  longer  dark  and  clear,  but  is 
occupied  by  a  whitish  opalescent  body,  which  lies  close  behind  it.  It  is 
different,  however,  when  the  affection  is  incipient  and  but  slightly 
advanced,  more  especially  when  the  opacity  commences  at  the  edge  of 
the  lens,  for  it  may  then  be  easily  overlooked  except  the  eye  is  cai'efully 
examined  with  the  ophthalmoscope  and  the  oblique  illumination.  If 
elderly  persons  complain  somewhat  of  dimness  of  sight,  the  condition 


218  DISEASES  OF   THE   CRYSTALLINE   LENS. 

of  the  lens  should  always  be  examined,  even  although  they  naay  appa- 
rently be  only  suffering  from  presbyopia,  and  are  able  to  read  the 
smallest  print  with  suitable  convex  glasses  ;  for  amongst  the  aged  cata- 
ract is  most  common,  and  often  commences  at  the  very  edge  of  the 
lens  in  the  form  of  small  spicular  opacities,  which  might  easily  escape 
detection.  Wherever  incipient  cataract  is  suspected,  the  pupil  should  be 
dilated  by  a  weak  solution  of  atropine,  and  the  lens  examined  with  the 
ophthalmoscope  and  the  obhque  illumination.  If  there  is  any  objection 
to  dilating  the  pupil,  a  very  fair  view  may,  however,  be  obtained  even  of 
the  margin  of  the  lens,  by  directing  the  patient  to  turn  his  eye  to  one 
side,  and  then  looking  very  slantingly  behind  the  iris. 

Care  must,  however,  be  taken  not  to  mistake  the  physiological 
changes  which  occur  in  the  lens  in  old  age  for  commencing  cataract. 
These  changes  consist  in  a  thickening  and  consolidation  of  the  lens 
substance,  especially  of  the  nucleus,  which  assumes  a  yellow  tint.  If 
this  physiological  cloudiness  is  very  marked,  it  might  easily  be  mis- 
taken for  incipient  cataract.  The  chief  distinctive  features  are,  that  in 
the  former  case  the  sight  is  perfect  (any  existing  presbyopia  being  cor- 
rected by  suitable  glasses),  the  opacity  remains  absolutely  or  almost 
entirely  stationary  for  a  very  long  period,  and  the  cloudiness  is  not 
observable  with  the  ophthalmoscope,  although  perhaps  very  evident 
with  the  oblique  illumination. 

The  catoptric  test,  which  was  formerly  much  employed  in  the  diag- 
nosis of  cataract,  has  fallen  into  complete  disuse  since  the  discovery  of 
the  ophthalmoscope,  and  the  introduction  of  the  oblique  illumination. 
The  catoptrical  examination  depended  upon  the  three  images  which 
may  be  observed  in  a  healthy  eye  when  a  lighted  taper  is  moved  before 
it.  Two  of  these  images  are  erect,  the  third  is  inverted.  The  first  is 
an  erect  image  of  the  candle,  and  is  produced  by  reflection  from  the 
surface  of  the  cornea ;  the  second  is  also  erect,  and  is  produced  by 
reflection  from  the  anterior  surface  of  the  lens ;  the  third  is  inverted, 
and  is  due  to  reflection  from  the  concave  posterior  surface  of  the  lens. 
The  first  two  images  move  in  the  same  direction  as  the  candle,  the  third 
in  the  opposite  direction.  If  the  lens  becomes  opaque,  of  course  the 
image  from  the  posterior  surface  is  lost,  and  that  from  the  anterior 
surface  also  soon  becomes  indistinct. 

With  the  oblique  illumination,  opacities  in  the  lens  will  appear  of  a 
light  grey,  or  whitish  colour.  The  slighter  forms  are  best  seen  by  only 
a  moderate  amount  of  light. 

In  employing  the  ophthalmoscope  for  the  diagnosis  of  cataract,  the 
miiTor  alone  is  to  be  used  (without  any  lens  in  front).  To  gain  a  larger 
image,  a  convex  lens  may  be  placed  behind  the  mirror.  The  illumina- 
tion is  to  be  weak.  Incipient  cortical  cataract,  composed  of  centripetal 
stripes,  will  appear  in  the  form  of  well-defined  dark  streaks  upon  a  red 


CATARACT.  219 

back  ground.  Punctlform  opacities  also  appear  as  dark  spots,  but  are 
often  not  so  observable  as  with  the  oblique  illumination. 

I  will  now  briefly  describe  the  characteristic  appearances  presented 
by  the  different  forms  of  cataract. 

I.  Lamellar  or  zonular  cataract  (ScliicJdstaar)  is  generally  con- 
genital or  developed  in  early  infancy.  Arlt  originally  called  attention 
to  the  fact  that  it  often  occui-s  in  children  who  have  suffered  from 
convulsions,  but  the  connexion  between  the  two  has  not  yet  received  a 
satisfactory  explanation ;  for  it  is  difficult  to  understand  why  only 
certain  perinuclear  layers  of  the  lens  fibres  should  be  affected  by  the 
mal-nutrition  or  succussion  consequent  upon  the  violent  muscular 
efforts  dui'ing  the  convulsions. 

As  lamellar  cataract  does  not  materially  impair  the  sight,  it  often 
escapes  detection  until  much  later  in  life.  Its  appearance  is  very  cha- 
racteristic, and  its  diagnosis  easy.  On  dilating  the  pupil  with  atropine, 
we  observe  an  opacity  of  the  lens  measuring  from  two  to  three  and  a  half 
lines  in  diameter.  It  is  quite  uniform  from  the  periphery  to  the  centre, 
and  is  sharply  defined  against  the  transparent  margin  of  the  lens.  The 
cataract  consists,  in  short,  of  a  layer  of  opaque  lens  substance  lying 
between  the  nucleus  and  a  transparent  portion  of  the  cortical  substance. 
Hence  it  has  been  designated  "  Schichtstaar,"  or  lamellar  cataract.  The 
nucleus  of  the  lens  is  transparent,  which  is  proved  by  the  uniform  cha- 
racter of  the  opacity,  which  is  not  more  dense  in  the  centre  than  at  the 
periphery,  and  by  the  relatively  fair  sight  which  such  patients  enjoy 
even  when  the  pupil  is  not  dilated.  Moreover,  with  the  ophthalmoscope, 
a  reddish-brown  reflex  shines  through  the  central  portion  of  the  lens. 

With  the  oblique  illumination,  the  opacity  appears  of  a  uniform  light 
grey  colour,  sharply  defined,  and  surrounded  by  a  more  or  less  broad 
margin  of  transparent  cortical  substance.  It  will  now  also  be  seen  that 
there  is  a  clear  portion  of  cortical  substance  between  the  opacity  and 
the  anterior  capsule.  In  the  centre  of  the  opacity  may  often  be 
remarked  one  or  more  small  white  spots.  With  the  ophthalmoscope, 
the  opacity  has  the  appearance  of  a  well  defined  dark  disc,  the  centre 
of  which  affords  a  reddish-brown  reflex.  If  the  margin  of  the  cortical 
substance  be  clear,  the  details  of  the  fundus  will  be  visible  through  it. 
If  there  are  opacities  in  it,  they  will  appear  as  fine  dark  stripes 
or  specks  upon  a  red  background.  Some  of  the  varieties  of  lamellar 
cataract  are  very  pretty.  For  instance,  I  have  seen  cases  in  which  little 
stripes  ran  from  the  opacity  into  the  cortex,  their  extremities  being 
studded  with  small,  pearl-like  opacities.  Lamellar  cataract  is  either 
stationary  or  very  slowly  progressive.  It  is,  therefore,  of  consequence, 
before  deciding  upon  an  operation,  to  determine  whether  the  cataract 
be  progressive  or  not.  In  deciding  this,  we  must  be  chiefly  guided  by 
the  condition  of  the  marginal  cortical  substance.     If  the  latter  is  per- 


220  DISEASES   OP   THE   CRYSTALLINE  LENS. 

fectly  clear  and  transparent,  the  cataract  is  stationary ;  if  it  is  diffusely 
clouded,  or  presents  punctiform  or  striped  opacities,  it  is  progressive. 
Von  Graefe  tMnks  that  its  progress  is  most  rapid  when  the  stripes  are 
broad,  and  the  interjacent  lenticular  substance  is  somewhat  opaque  and 
studded  with  coarse  specks.  If  the  opacities  consist  only  of  very  fine 
dots,  or  a  few  delicate  narrow  stripes,  the  progress  is  very  slow. 

According  to  Von  Graefe,  lamellar  cataract  may  also  be  formed  later 
in  life  in  dislocated  lenses,  and  after  iritis. 

'Vision  may  be  relatively  good  if  the  opacity  is  not  dense;  for  instance 
large  print  ruay  be  read.  But  the  sight  is  always  improved  by  dila- 
tation of  the  papil  with  atropine,  for  this  permits  the  rays  from  the 
object  to  pass  through  the  clear  marginal  portion  of  the  lens.  I 
have  seen  cases  in  which  the  difference  in  the  sight,  before  and  after 
dilatation  of  the  pupil,  has  been  most  marked ;  so  that  persons  who, 
prior  to  it,  could  with  difficulty  decipher  large  letters,  were  afterwards 
able  to  read  the  smallest  print.  The  accompanying  diagrams  (Figs.  26 
and  27)  ^vill  explain  this.     Fig.  26  (a)  the  undilated  pupil  occupied  by 


Fig.  27. 


the  opacity  (i),  which  extends  beneath  the  iris  as  far  as  the  dotted  hne 
(c),  where  the  transparent  margin  (rf)  commences.  As  the  latter  is 
completely  covered  by  the  iris,  the  rays  can  only  pass  through  the 
central  opaque  portion  ;  hence  the  indistinctness  of  sight.  But  on  dila- 
tation of  the  pupil  (Fig.  27)  the  transparent  margin  (d)  is  exposed,  and 
the  rays  can  now  pass  through  it  to  the  retina.  The  solution  of  atropine 
to  be  used  for  dilating  the  pupil  should  be  extremely  weak  (gr.  j.  to 
eight  or  twelve  ounces  of  water),  so  that  w:e  may  obtain  complete  dila- 
tation of  the  pupil  without  any  paralysis  of  the  accommodation.  If 
this  point  is  not  attended  to,  we  may  easily  be  misled  by  the  fact  of  the 
])atient's  complaiaing  that  after  the  dilatation  the  sight  is  dim  and  misty, 
which  may  be  due  simply  to  the  fact  that  the  accommodation  is  paralysed 
by  the  atropine,  which  was  too  strong. 

Persons  suffering  from  lamellar  cataract  are  often  supposed  to  be 
short-sighted,  as  they  hold  small  objects  (a  book,  for  instance)  very  close 
to  the  eye,  in  order  to  gain  larger  retinal  images.  In  time,  however, 
this  constant  accommodation  for  very  near  objects  may  really  give  rise 
to  myopia  of  even  a  considei-able  degree. 

In  practice,   it  is  important  to  remember  two  facts  with  regard  to 


CATARACT.  221 

lamellar  cataract — 1.  That  the  opacity  is  surrounded  by  a  more  or  less 
clear  margin  of  cortical  substance,  which,  if  it  be  sufficiently  wide  and 
transparent,  may  admit  of  excellent  sight  when  the  pupil  is  dilated.  2. 
That  the  greater  portion  of  the  lens  is  transparent  and  in  a  normal 
condition,  and  will,  therefore,  swell  up  far  more  than  a  cataractous  lens, 
after  laceration  of  the  capsule  and  the  admission  of  the  aqueous  humour, 
as,  for  instance,  in  a  needle  operation. 

II.  Cortical  Cataract. — The  opacity  generally  commences  at  the 
margin.  Small,  greyish- white  stripes  are  observed  running  towards 
the  centre  of  the  lens.  At  the  very  commencement,  the  interjacent  lens 
substance  is  either  perfectly  transparent,  or  but  sparsely  studded  with 
little  opaque  dots.  Soon,  however,  the  cloudiness  becomes  more  general 
and  diffuse,  until  the  whole  lens  is  involved.  Sometimes  the  stripes  may 
be  observed  both  on  the  anterior  and  posterior  cortical  substance,  the 
lens  between  them  being  transparent.  The  difference  in  their  position 
may  be  easily  recognised  with  the  oblique  illumination.  The  anterior 
stripes  are  close  behind  the  pupil,  w^iereas  the  others  are  far  back  in 
the  eye,  and  appear  concave,  the  concavity  being  turned  towards  the 
observer. 

On  examining  an  incipient  cortical  cataract  with  the  ophthalmoscope, 
we  notice  dark,  well-defined  stripes  intersecting  the  red  background, 
and  radiating  from  the  margin  of  the  lens  to  the  centre.  Between  them, 
at  the  very  edge  of  the  lens,  there  is  often  a  fringe  of  short,  stunted 
stripes.  Punctiform  opacities,  which  with  the  oblique  illumination 
appeared  of  a  grey  colour,  now  look  like  little  dark  dots  strewn  about  on 
and  between  the  stripes. 

In  rare  instances  the  opacity,  instead  of  being  striped,  consists  of 
innumerable  little  dots  with  clear  portions  of  lens  substance  between 
them.     With  the  naked  eye  it  looks  like  a  diffuse  uniform  opacity. 

The  following  symptoms  are  characteristic  of  a  fully  formed,  mature 
cortical  cataract : — The  opacity  is  of  a  grey  or  bluish- white  colour,  which 
increases  somewhat  in  density  towards  the  centre.  On  account  of  this 
white  tint,  the  movements  of  the  pupil  appear  peculiarly  marked  and 
distinct.  If  the  volume  of  the  lens  be  increased  through  the  imbibition  of 
fluid,  the  iris  may  be  slightly  arched  forward,  and  the  pupil  somewhat 
dilated  and  sluggish.  The  stripes  are  broad,  white,  and  often  very 
opalescent,  like  mother  of  pearl.  There  is  no  admixture  of  yellow  in 
the  colour  of  the  opacity,  which  proves  at  once  that  the  nucleus  is  not 
hard.  With  the  oblique  illumination,  we  notice  that  the  outer  layers  of 
the  cortical  substance,  although  opaque,  are  somewhat  translucent,  so 
that  we  can  see  through  them  into  the  deeper  layers.  This  is  of  im- 
portance with  regard  to  the  consistence,  for  in  the  very  soft  or  the  fluid 
cataract  the  dense  white  opacity  reaches  quite  up  to  the  capsule,  and  is 
not  at  all  diaphanous. 


222  DISEASES   OF   THE   CRYSTALLINE   LENS. 

Von  Graefe*  calls  attention  to  a  peciiliar  form  which  is  sometimes 
met  with  in  early  infancy.  Its  diagnosis  is  of  special  importance,  as  it 
is  very  frequently  complicated  with  lesions  of  the  deeper  structures  of 
the  eyeball.  It  commences  as  a  milky- white  cloud  in  the  outer  portions 
of  the  cortical  substance,  and  soon  reaches  quite  up  to  the  capsule. 
The  opacity  is  either  completely  homogeneous,  or  studded  with  small 
white  dots  which  extend  close  up  to  the  capsule.  The  lens,  which  is  at 
first  somewhat  increased  in  volume,  soon  diminishes  again  in  size  on 
account  of  the  absorption  of  its  fluid  constituents.  In  cases,  therefore, 
in  which  the  volume  of  the  lens  is  much  diminished,  and  considerable 
opacities  are  lodged  in  the  central  portions  of  the  anterior  capsule,  the 
degree  of  sight  and  the  state  of  the  field  of  vision  should  always  be  care- 
fully tested  prior  to  an  operation,  in  order  that  the  existence  of  any 
deep-seated  lesion  may  be  detected. 

The  progress  of  cortical  cataract  is  generally  rapid,  more  especially 
in  children,  in  whom  it  may  become  mature  in  the  course  of  a  few  weeks 
or  months.  In  adults  it  may  increase  but  slowly,  particularly  if  the 
stripes  are  narrow  and  few  in  niimber.  Broad  stripes  and  large  floccu- 
lent  opacities  indicate  a  rapid  progress.  This  form  is  not  unfrequently 
confined  to  one  eye.  As  cataract  is  not  of  very  common  occurrence 
even  before  the  age  of  fifty,  we  should  always  ascertain  whether  it  may 
not  have  been  produced  by  some  special  cause,  such  as  injury  to  the 
lens  or  internal  inflammation  of  the  eye.  If  both  eyes  are  affected,  the 
urine  should  be  tested  for  the  presence  of  sugar,  as  diabetes  is  a  not 
unfrequent  cause  of  cataract. 

Cortical  cataract  is  always  soft.  In  children  it  may  be  almost  fluid. 
Although  its  consistence  increases  with  advancing  years,  it  is  generally 
up  to  the  age  of  thirty  or  thirty-five  free  from  a  hardish  nucleus,  and 
sufiiciently  pulpy  to  be  readily  removed  by  linear  extraction. 

When  a  mature  cortical  cataract  has  existed  for  some  time,  it  may 
undergo  certain  retrogressive  changes.  Its  fluid  and  fatty  constituents 
may  become  absorbed,  and  the  cortical  substance  become  more  dry  and 
consolidated.  As  absorption  proceeds,  the  cataract  shrivels  up,  the 
anterior  capsule  becomes  wrinkled  and  recedes  from  the  pupil,  so  that 
a  more  or  less  deep  posterior  chamber  is  formed. 

The  capsule  sometimes  looks  like  a  little  wi'inkled  bag,  containing 
small  white  chalky  chips  of  lens.  In  very  young  subjects  the  greater 
portion  of  the  lens  may  become  absorbed,  so  that  finally  there  is  nothing 
left  but  a  small  white  shrivelled  disc,  of  a  hard  chalky  consistence. 
This  is  the  chalky  or  "  siliculose  "  cataract  of  old  writers.  Although 
this  form  may  occur  simply  as  the  result  of  the  absorption  of  the  softer 
constituents  of  an.  ordinary  cataract,  it  is  still  more  frequently  met  with 
in  deep-seated  inflammatory  lesions  of  the  eyeball,  as,  for  instance,  in 

*  "A.  f.  0.,"i,  2. 


CATARACT.  223 

the  latter  stages  of  irido- choroiditis.  But  the  fluid  constituents,  instead 
of  becoming  absorbed,  may  increase,  the  structure  of  the  lens  breaking 
down,  so  that  the  cataract  may  become  extremely  soft  or  even  fluid, 
which  is  especially  the  case  in  children.  In  adults,  more  particularly 
after  the  age  of  thirty,  the  harder  nucleus  sets  a  limit  to  the  process  of 
softening,  which  can  then  only  afiect  the  cortex  and  not  the  whole  lens. 
Now,  if  in  such  cases  the  cortical  substance  becomes  fluid,  the  hard 
yellow  nucleus  will  sink  down  in  it,  and  thus  the  so-called  "  Morgagnian" 
cataract  will  be  produced. 

The  chief  characteristics  of  fluid  cataract  are,  that  the  opacity  is  of 
a  milky- white  or  dirty  grey  colour,  that  it  is  homogeneous,  and  that  it 
reaches  quite  up  to  the  anterior  capsule,  on  the  inner  side  of  which  are 
often  observed  small  wliite  dots.  There  are  no  opalescent  stripes,  and 
the  anterior  layers  of  the  cortex  are  not  translucent. 

III.  The  Nuclear  or  Hard  Senile  Gatarad. — It  has  been  already  stated 
that  after  the  age  of  from  thirty  to  thirty-five  the  lens  undergoes  certain 
physiological  changes.  The  nuclear  portion  becomes  firmer  and  more 
consolidated,  and  assumes  a  yellow  tint.  This  condition  may  exist  for 
many  years  without  any  marked  increase,  without  deterioration  of  sight, 
or  without  any  opacity  being  observable  with  the  ophthalmoscope  ;  but 
the  division  between  the  physiological  and  pathological  consolidation  and 
cloudiness  is  only  one  of  degree.  When  these  senile  changes  increase  to 
such  an  extent  that  the  sight  is  perceptibly  impaired,  and  when  the 
opacity  of  the  lens  is  progressive  and  becomes  marked  even  by  trans- 
mitted light,  I  think  that  we  must  then  no  longer  consider  it  as  a 
physiological  condition,  but  as  commencing  nuclear  cataract.  In  the 
latter  case  the  nucleus  presents  a  marked  yellow  or  yellowish-brown 
tinge,  and  is  easily  distinguishable  from  the  cortical  substance,  which 
may  remain  clear,  except  perhaps  in  the  immediate  vicinity  of  the 
nucleus.  With  the  oblique  illumination  the  cataract  will  appear  as  a 
round  yellow  opacity,  situated  some  distance  behind  the  pupil.  The 
anterior  layers  of  the  cortical  substance  are  translucent  and  transparent, 
so  that  we  can  see  through  them  into  the  centre  of  the  lens,  and  the 
pupil  throws  a  deep  shadow  upon  the  surface  of  the  opacity.  The 
nuclear  cataract  may  be  very  dark,  even  black  in  colour,  which  is  due 
to  the  imbibition  of  hgematine.  The  "  black  cataract  "  may  easily  be 
overlooked  if  the  eye  is  not  examined  with  the  ophthalmoscope  or  the 
oblique  illumination. 

Pure  nuclear  cataract  is  but  rarely  met  with.  In  the  great  majority 
of  cases  of  senile  cataract  the  cortex  is  also  aflected,  so  that  we  have  in 
truth  a  mixed  form — viz.,  a  hard  yellow  nucleus  with  a  more  or  less  firm 
cortical  substance.  I  think  it  well,  however,  to  retain  the  name  of 
"nuclear  "  cataract  for  the  senile  form,  as  indicating  the  presence  of  a 
hardish  nucleus. 


224  DISEASES   OF   THE   CRYSTALLINE  LENS. 

Senile  cataract  generally  commences  at  the  periphery  of  the  lens  in 
the  form  of  small  centripetal  stripes,  between  which  Ave  may  often  notice 
smaller  and  shorter  spikes,  situated  at  the  very  margin  of  the  lens.  The 
stripes  may  run  along  the  anterior  or  posterior  surface  of  the  lens,  the 
interjacent  substance  being  clear.  The  opacity  gradually  becomes  more 
general,  and  involves  more  and  more  the  centre  of  the  lens  ;  the  intervals 
between  the  stripes  becoming  clouded  and  perhaps  studded  with  small 
opaque  dots  or  patches.  As  the  cataract  progresses,  the  distinction 
between  the  nucleus  and  the  cortex  becomes  more  marked,  the  former 
showing  a  distinct  yellow  tint. 

Sometimes  the  stripes  commence  in  the  posterior  cortex,  extending 
from  the  margin  to  the  posterior  pole  of  the  lens,  where  they  coalesce, 
the  opacity  thus  assuming  a  stellate  appearance.  The  intervals  between 
the  stripes  may  remain  transparent  for  some  time,  as  also  the  nuclear 
portion  of  the  lens,  so  that  we  can  see  quite  to  the  back  of  the  latter. 
The  view  of  the'  background  of  the  eye  is  of  course  obscured  in  the 
centre  by  the  confluence  of  the  stripes,  but  if  the  segments  between 
them  are  clear,  we  may  yet  at  the  periphery  distinguish  the  details  of 
the  fundus ;  such  forms  are  often  extremely  slow  in  their  progress. 
When  opacities  commence  at  the  posterior  pole  of  the  lens,  either  in  the 
form  of  centripetal  stripes  or  of  circumscribed  spots  or  patches,  the 
general  condition  of  the  eye  should  be  carefully  examined,  as  this  form 
of  cataract  (posterior  polar  cataract)  not  unfrequently  shows  itself  in 
the  latter  stages  of  sclerotico-choroiditis  posterior,  retinitis  pigmentosa, 
detachment  of  the  retina,  and  other  deep-seated  lesions.  The  co-exist- 
ence of  any  such  complication  would,  of  course,  materially  afiect  oui* 
prognosis  of  the  result  of  an  operation. 

We  occasionally  meet  with  incipient  cataracts  in  which  there  is  a 
marked  difference  between  the  amount  of  the  opacity,  according  to 
whether  the  oblique  illumination  or  the  ophthalmoscope  be  used  for 
examination.  On  account  of  the  great  opalescence  of  the  stripes,  it  is 
very  apparent  to  the  naked  eye  and  with  the  oblique  illumination ;  yet, 
on  testing  the  vision,  we  find  it  surprisingly  good,  and  with  the  oph- 
thalmoscope we  can,  with  a  little  management,  cleai'ly  distinguish  the 
details  of  the  fundus.  I  have  noticed  this  peculiarity  several  times  in 
myopic  patients ;  the  progress  has  generally  been  very  slow. 

In  the  majority  of  cases,  one  of  the  first  symptoms  noticed  by  a 
person  affected  with  incipient  cataract  is,  that  distant  objects  appear 
somewhat  indistinct  and  hazy,  or  as  if  surrounded  by  a  halo.  After  a 
time,  near  objects  also  become  indistinct,  and  in  reading,  the  print  has 
to  be  approximated  closer  to  the  eye  or  observed  through  a  strong 
convex  lens,  in  order  that  a  larger  retinal  image  may  be  gained.  If  the 
opacity  is  chiefly  or  entirely  confined  to  the  centre  of  the  lens,  the 
margin  being  clear,  the  patient  will  see  best  when  his  back  is  turned  to 


CATARACT.  225 

the  light,  or  when  he  shades  the  eye  with  his  hand,  so  that  the  pn])il 
becomes  somewhat  cnhirged.  Dilatation  of  the  pupil  by  a  very  weak 
solution  of  atropine  will  have  the  same  effect.  If  the  cloudiness  be 
confined  to  the  margin  of  the  lens,  the  reverse  will  obtain  ;  the  sight 
will  be  best  when  the  pupil  is  small. 

Sometimes,  persons  suffering  from  incipient  senile  cataract  com- 
plain that  they  are  getting  myopic,  requiring  the  aid  of  a  concave 
glass  in  order  to  distinguish  distant  objects.  The  reason  of  this  fact  is 
somewhat  doubtful,  and  can  only  be  explained  upon  the  supposition 
that  there  is  some  increase  in  the  volume  of  the  lens  which  gives  it  a 
higher  refractive  power. 

It  was  formerly  thought  that  senile  cataract  almost  always  com- 
menced at  the  centre  of  the  lens,  and  extended  thence  towards  the 
margin.  This  opinion  led  to  great  mistakes,  and  caused  incipient 
cataract  to  be  often  entirely  overlooked. 

On  examining  a  mature  senile  cataract  with  the  oblique  illumina- 
tion, we  at  once  notice  the  presence  of  a  yellow  nucleus.  Its  size  may 
be  estimated  from  the  extent  of  the  yellow  reflex,  its  hardness  from  the 
depth  of  the  coloui\  The  darker  the  yellow  tint,  the  harder  and  more 
compact  will  the  nucleus  be.  The  cortical  substance  is  of  a  grey  or 
bluish-white  colour,  traversed  by  numerous  centripetal  opalescent 
stripes,  and  studded  perhaps  with  small  white  dots  or  patches. 

The  rate  of  progress  of  senile  cataract  is  very  difficult  to  determine 
with  accuracy.  It  is  far  more  rapid  in  the  cortex  than  in  the  nucleus. 
Sometimes,  years  may  elapse  before  it  arrives  at  maturity.  It  m.ay 
remain  at  an  incipient  stage  for  a  very  long  time  without  apparently 
making  any  progress,  and  then  suddenly  advance  very  rapidly,  arriving 
at  maturity  within  a  few  months  or  even  weeks.  We  must,  therefore, 
always  be  upon  our  guard  against  giving  a  decided  opinion  as  to  when 
any  given  case  of  incipient  cataract  will  be  fully  formed  and  fit  for 
operation.  Patients  are  sure  to  ask  this  question,  and  we  may  fall  into 
great  mistakes  by  giving  a  decided  answer.  This  can  only  be  pre- 
dicted with  anything  like  certainty,  when  the  prog-ress  of  the  case  has 
been  constantly  watched.  As  a  general  rule,  I  may  state  that  if  the 
cortical  substance  presents  broad,  white,  opalescent  stripes  and  large 
flakes  or  spots,  the  progress  is  more  rapid  than  if  the  stripes  or  spots 
are  small  and  narrow,  and  the  intermediate  lens-substance  clear. 

Senile  cataract  occurs  most  fi-equently  after  the  age  of  50  or  55, 
and  sooner  or  later  generally  affects  both  eyes. 

When  a  mature  senile  cataract  has  existed  for  some  length  of  time, 
it  may  also  undergo  some  retrogressive  changes  ;  but  these  are  far  less 
than  in  the  cortical  cataract,  for  they  only  affect  the  cortical  substance 
and  not  the  nucleus,  which  becomes  harder  and  firmer.  The  fluid  con- 
stituents may  be  partially  absorbed,  and  some  of  the  elements  may 

Q 


226  DISEASES   OF   THE   CRYSTALLINE  LENS. 

■undergo  a  fatty  or  chalky  degeneration,  so  that  the  cataract  diminishes 
in  thickness  and  becomes  flatter,  but  is  very  coherent.  The  molecules 
are  aggregated  together  into  small  masses,  which  become  adherent  to 
the  inner  surface  of  the  capsule,  or  are  often  collected  at  the  margin  of 
the  lens.  They  may  prove  in  so  far  dangerous,  that  they  are  very  apt 
to  remain  behind  in  the  capsule  when  the  cataract  is  extracted,  and  give 
rise  to  secondary  cataract.  In  very  rare  instances,  a  great  portion  of 
the  cataract  may  be  absorbed  and  the  sight  of  the  patient  materially 
improved.  In  the  majority  of  cases,  the  yellow  nucleus  may  still  be 
seen  shining  through  the  cortical  substance,  but  now,  however,  no 
longer  in  the  centre,  but  sunk  down  to  the  bottom  of  the  capsule 
(Morgagnian  cataract) .  If  the  cortical  substance  is  grej,  very  opaque, 
and  pretty  uniformly  studded  with  fine  dots  or  patches,  it  may  be 
considered  as  soft,  not,  however,  pulpy  or  diffluent,  but  friable,  so  that 
small  coherent  portions  are  apt  to  remain  behind,  and  adhere  to  the 
pupil  or  the  corneal  section  after  the  chief  portion  of  the  cataract  is 
removed. 

2.— TRAUMATIC  CATARACT. 

When  the  capsule  is  perforated  or  torn  by  a  sharp  instrument,  the 
aqueous  humour  is  admitted  to  the  lens  substance,  which  may  become 
rapidly  opaque.  If  the  perforation  is  extremely  small  and  superficial, 
such  as  might  be  produced  by  a  very  fine  needle,  the  danger  may  be  but 
slight.  The  lips  of  the  wound  in  the  capsule  may  unite,  and  no  per- 
manent, or  only  a  very  limited,  opacity  may  remain ;  but  if  the  wound 
is  larger,  much  aqueous  humour  is  admitted,  the  lens  will  swell  up  very 
rapidly,  and  will  press  upon  the  iris  and  ciliary  body.  The  iris  is  often 
considerably  lacerated,  or  protrudes  through  the  corneal  wound,  and 
this  greatly  increases  the  irritation  and  danger  of  severe  inflammation. 
Flakes  of  softened  lens  matter,  or  broken  portions  of  lens,  fall  into  the 
anterior  chamber,  and,  coming  in  contact  with  the  anterior  surface  of 
the  iris,  produce  great  irritation ;  or  portions  of  lens  matter  may  exude 
through  or  become  entangled  in  the  wound.  The  inflammation,  which 
may  involve  the  iris,  ciliary  body,  and  choroid,  may  assume  either  a 
purulent  or  a  serous  character.  In  the  latter  case,  there  may  be  more  or 
less  increase  in  the  intra-ocular  tension,  with  the  attendant  train  of 
glaucomatous  symptoms.  In  children  the  danger  of  secondary  inflam- 
mation is  less  than  in  adults,  as  the  lens  is  softer,  the  iris  less  impatient 
of  pressure,  and  absorption  more  rapid ;  in  fact,  the  lens  may  be  almost 
entirely  absorbed,  so  that  finally  there  only  remains  a  small,  hard, 
white  disc.  The  lens  becomes  more  rapidly  opaque  in  the  young  than 
in  elderly  persons.  I  have  occasionally  met  with  cases  in  youthful 
individuals  in  which,  a  few  days  after  the  injury  to  the  lens,  the  latter 
had  become  almost  completely  cataractous.     The  swelling  of  the  lens 


r 


CATARACT.  227 

is  often  very  considerable,  so  that  its  volume  is  mucli  increased ;  the 
iris  is  consequently  pushed  forward  and  the  anterior  chamber  diminished 
in  size.  This  pressure  of  the  swollen  lens  upon  the  iris  and  ciliary 
body  produces  great  irritation,  and  may  give  rise  to  severe  irido-cyclitis.  L     o 

The  danger  is  very  great  when  a  foreign  body — e.g.,  a  piece  of  gun  cap  (  •'^^  f' 
or  a  chip  of  steel — is  lodged  in  the  lens,  or,  having  passed  through  it, 
is  fixed  in  the  deeper  tissues  of  the  eye,  as  it  is  frequently  followed  by  ^ 
a  most  destructive  inflammation.  After  any  injury  to  the  lens,  the 
history  of  the  accident  should  be  inquired  into,  and  if  it  was  caused  by 
a  chip  of  steel,  a  shot,  etc.,  the  condition  of  the  eye  must  be  carefully 
examined,  in  order  that  we  may,  if  possible,  ascertain  whether  the 
foreign  body  be  still  in  the  eye,  and  whereabouts  it  is  situated.  After 
an  injury  to  the  lens,  the  condition  of  the  eye  must  be  anxiously  watched. 
The  tension  of  the  eyeball,  the  state  of  the  sight  and  of  the  field  of  vision 
must  be  frequently  examined,  so  that  the  earliest  symptoms  of  any 
glaucomatous  complication  may  be  detected,  and,  if  possible,  cut  short. 
The  danger  of  sympathetic  ophthalmia  must  also  be  kept  in  mind.  A 
traumatic  cataract  may  also  be  produced  through  a  simple  contusion 
of  the  eye  without  any  laceration  or  rupture  of  the  external  coats  of 
the  eye.  Thus  a  blow  upon  the  eye  or  over  the  head  from  the  fist,  or 
some  blunt  body  (a  piece  of  wood,  whip,  etc.)  may  give  rise  to  trau- 
matic cataract.  Special  attention  to  this  fact  was  called  by  Mr.  Law- 
son  some  years  ago,  who  recorded  several  instances  of  the  kind.*  In 
such  cases,  however,  the  capsule  is  generally  ruptured,  in  most  instances, 
as  was  pointed  out  by  Von  Graefe,t  at  the  periphery  of  the  lens,  just 
where  the  thick  anterior  passes  into  the  thin  posterior  capsule.  Some- 
times, however,  no  tear  in  the  capsule  can  be  detected. 

3.— CAPSULAR  CATARACT. 

Capsular  cataract  presents  a  white,  chalky  appearance,  and  is  situated 
in  the  area  of  the  piipil.  Strictly  speaking,  this  term  is  inaccurate,  for 
the  capsule  itself  appears  never  to  become  opaque,  for  although  it  may 
become  wrinkled  and  changed  in  thickness,  it  retains  its  transparency. 
According  to  Heinrich  Midler,  J  these  opacities  are  not  owing  to  any 
changes  in  the  structure  of  the  capsule  itself,  but  are  situated  at  its 
inner  side,  and  are  due  to  the  deposition  of  new  layers  of  a  substance 
which  is  often  much  akin  in  its  nature  to  that  of  the  capsule,  but  in 
other  cases  is  of  a  fibrous  character.      Schweigger§  insists  strongly 

*  Vide  "  R.  L.  O.  H.  Eep.,"  iv,  179 ;  also  Mr.  Lawson's  book,   "  On    Injuries 
of  the  Eye,"  p.  130. 

t  "Kl.  Monatsbl.,"  1864,  19.     A  translation  of  this  Lecture  upon  Traumatic 
Cataract  will  be  foimd  in  the  "Opbth.  ReTiew,"  ii,  137. 

X  "  Archiv.  f.  Opbthal.,"  iii,  1,  56. 

§  Ibid.,  viii,  1,  227. 

Q  2 


228  DISEASES  OF   THE   CRYSTALLINE   LENS. 

upon  the  fact  that  capsular  cataract  only  occurs  as  a  complication  of  a 
previous  cataractous  opacity  of  the  lens.  Thus,  when  the  fluid  con- 
stituents become  absorbed  in  a  retrograding  cataract,  the  harder 
portions  may  become  adherent  to  the  inner  portion  of  the  capsule,  and 
thus  produce  an  opacity  of  the  latter.  The  intra-capsular  cells  are 
either  not  at  all,  or  but  slightly  involved  in  an  uncomplicated  cataract ; 
but  if  it  is  complicated  with  irido- choroiditis,  great  proliferation  of 
these  cells  takes  place,  and  they  have  a  considerable  share  in  the 
formation  of  the  capsular  cataract.  The  capsule,  although  transparent, 
is  often  somewhat  wrinkled.  As  capsular  cataract  occurs  most  fre- 
quently in  the  later  stages  of  irido-choroiditis,  the  history  of  the  case 
and  the  general  condition  of  the  eye  must  be  carefully  exam.ined  before 
any  operation  is  undertaken. 

Anterior  central  capsular  cataract  may  be  congenital,  but  is  more 
frequently  formed  in  early  childhood  in  consequence  of  a  perforating 
ulcer  of  the  cornea.  It  occurs  in  this  way :  if  an  ulcer,  which  is 
situated  at  or  near  the  centre  of  the  cornea,  perforates  the  latter,  the 
aqueous  humour  escapes,  the  iris  and  lens  fall  forward,  and  come  in 
contact  with  the  cornea.  Plastic  lymph  is  efiused  into  the  ulcer,  and  a 
little  nodule  of  this  is  deposited  upon  the  centre  of  the  capsule.  As 
the  pupil  contracts  on  the  escape  of  the  aqueous  humour,  only  the 
central  portion  of  the  capsule  remains  uncovered  by  the  iris,  and  tlris  is, 
therefore,  the  place  where  the  cataract  is  formed.  As  the  nutrition  of 
the  lens  is  impaired  near  the  deposit  of  lymph,  the  superficial  layers  of 
cortical  substance  in  its  vicinity  become  somewhat  opaque.  The 
ulcer  of  the  cornea  heals,  the  iris  and  lens  recede  to  their  former 
position,  but  the  opacity  on  the  anterior  capsule  remains.  If  the 
cornea  subsequently  becomes  transparent,  the  origin  of  the  capsular 
cataract  may  remain  unsuspected.  When  this  central  capsular  cataract 
is  very  prominent,  and  elevated  above  the  surface  of  the  capsule,  it  has 
been  termed  '''■  puramidal  cataract;''^  but  even  in  such  cases,  Miiller 
has  found  that  it  is  covered  by  transparent  capsule.  Mr.  Hutchinson* 
does  not  consider  that  the  form  of  cataract  is  generally  produced  by  a 
perforation  of  the  cornea  when  it  is  observed  to  occur  after  purulent 
ophthalmia.  He  believes  rather  that  "  the  mere  proximity  of  the  in- 
flammatory action  on  the  surface  of  the  conjunctiva  and  cornea  suffices 
to  disturb  the  nutrition  of  the  lens-capsule,  and  to  produce  deposits." 

I  will  now  pass  on  to  the  different  operations  suitable  to  various 
forms  of  cataract,  commencing  with  the  flap  extraction  ;  but  before  so 
doing,  I  must  touch  upon  certain  important  preliminary  considerations. 

It  is  generally  deemed  important  that  a  cataract,  especially  the 

*  Vide  Mr.  Hutchinson's  p.apcr,  "  On  Pyramidal  Cataracts,  with  speculations 
as  to  their  Cause." — R.  L.  O.  U.  Rep.,  vi,  136. 


CATARACT.  229 

senile  form,  should  be  mature  before  it  is  submitted  to  an  operation. 
In  mature  cataract  the  opacity  involves  the  whole  lens,  and  the  iris 
throws  little  or  no  shadow  upon  it.  The  sight  is  so  much  impaired 
that  the  patient  is  unable  to  distinguish  the  largest  print,  or  to  count 
fingers.  If  the  cataract  is  immature,  it  will  not  come  out  en  masse, 
but  the  transparent  portions  of  lens  substance  are  stripped  off,  and 
remain  adherent  to  the  capsule  or  the  edge  of  the  pupil.  They  swell 
up  very  considerably,  and  may  produce  great  inflammation  or  a  dense 
secondary  cataract.  These  observations  do  not  of  course  apply  to 
zonular  cataract,  which  may  never  become  mature.  The  question  now 
arises,  what  should  be  done  if  the  cataract  remains  immature  for  a  long 
time,  yet  is  so  advanced  as  greatly  to  impair  vision  ?  Can  we  hasten 
its  progi'ess  ?  Undoubtedly,  but  we  run  some  risk  in  so  doing — a  risk 
which  should  not,  I  think,  be  incui-red  except  under  peculiar  circum- 
stances. If,  for  instance,  a  person  who  is  entirely  dependent  upon  his 
sight  for  his  means  of  subsistence  is  affected  with  double  cataract, 
whose  progress  is  extrenaely  slow,  and  which,  though  very  immature, 
is  sufficiently  dense  to  prevent  his  following  his  customary  occupation, 
it  may  be  advisable  to  hasten  the  progress  of  the  cataract.  This  is  to 
be  done  by  gently  pricking  the  lens  with  a  fine  needle,  so  as  to  slightly 
divide  the  capsule  and  the  lens  substance,  and  admit  a  little  aqueous 
humour.  This  may  be  repeated  several  times,  care  being  taken  not  to 
divide  the  lens  too  freely  at  one  sitting,  lest  a  severe  iiitis  or  irido- 
choroiditis  be  set  up.  The  pupil  is  to  be  kept  widely  dilated  with 
atropine,  and  the  state  of  the  eye  narrowly  watched,  for  fear  of  any 
severe  inflammatory  symptoms  ensuing.  It  is  safer  still,  as  was  recom- 
mended by  Von  Graefe,  to  make  preliminary  iridectomy,  so  as  to  afford 
more  room  for  the  swelling  up  of  the  lens ;  moreover,  the  existence  of 
an  iridectomy  would  prove  of  advantage  when  the  final  operation  of 
removal  of  the  lens  is  performed.  But  not  many  patients  will  submit 
to  such  repeated  operations.  This  proceeding  is,  however,  accompanied 
by  the  disadvantage  that  it  necessitates  two  operations,  with  an  interval 
of  some  weeks  between  them.  This  often  proves  of  much  inconvenience 
and  anxiety  to  patients  w^ho  come  from  a  distance,  or  to  those  who  are 
of  a  very  timid  and  nervous  character.  Since  the  introduction  of  Yon 
Graefe's  new  operation,  I  must  confess  that  I  have  paid  less  heed  to 
the  necessity  of  waiting  with  the  operation  until  the  cataract  is  quite 
mature,  for  I  have  obtained  excellent  results  where  this  has  not  been 
the  case  ;  indeed,  I  have  removed  with  perfect  success  cases  of  lamellar 
cataract  in  persons  above  the  age  of  25.  As  a  rule,  I  should,  however, 
prefer  to  operate  on  a  cataract  which  is  quite  mature,  as  it  affords  a  better 
chance  of  complete  removal.  Again,  instead  of  hastening  the  progress 
of  the  cataract,  the  lens  may  be  removed  in  its  capsule,  which  obviates 
the  danger  of  unripe  portions  being  left  behind.     This  operation,  which 


230  DISEASES   OF   THE   CRYSTALLINE  LENS. 

has  been  strongly  advocated  by  Pagensteeher  and  Wecker,  I  shall  have 
occasion  to  speak  of  again.  Whilst,  on  the  one  hand,  it  is  dangerous 
to  operate  too  early,  it  may  also  be  wrong  to  wait  too  long  after  the 
cataract  is  fully  formed.  In  children  especially,  we  should  operate 
early,  for  otherwise  the  sight  and  the  sensibility  of  the  retina  may 
permanently  suffer,  and  oscillation  of  the  eyeball  (nystagmus)  may  also 
be  produced.  Later  in  life,  a  mature  cataract  may  exist  for  very  many 
years  without  the  sensibility  of  the  retina  being  affected  by  this  passive 
exclusion  from  the  act  of  vision.  But  in  children  it  is  different ;  in 
them  the  passive  suppression  of  the  retinal  image  produced  by  the 
cataract,  appears  to  exert  a  similar  influence  upon  the  sensibility  of  the 
retina,  as  the  active  suppression  which  occurs  in  cases  of  squint,  and 
which  often  rapidly  leads  to  great  amblyopia.  Again,  we  have  seen 
that  when  a  mature  cataract  has  existed  for  some  time,  it  may  undergo 
certain  retrogressive  changes,  its  fluid  constituents  may  become  ab- 
sorbed, fatty  or  calcareous  masses  may  be  collected  at  its  margin  or 
adhere  to  the  capsule,  and  remain  behind  when  the  lens  is  removed, 
giving  rise  to  inflammatory  complications  and  secondary  cataract.  It 
is  wiser,  therefore,  to  operate  before  such  secondary  changes  have  set  in. 

Should  we  operate  upon  the  one  eye  if  the  other  is  quite  free  from 
cataract  ?  I  think  it  is  advisable,  where  the  operation  is  almost  certain 
of  succeeding,  as,  for  instance,  in  the  discission  or  linear  extraction  of 
cataract  of  young  individuals.  The  operated  eye,  although  differing 
greatly  in  its  state  of  refraction  from  the  other,  will  still  assist  some- 
what in  the  act  of  vision.  The  visual  field  will  be  extended,  and  the 
fear  of  amblyopia  will  be  removed,  as  the  eye  may  be  separately  practised 
with  suitable  convex  glasses.  Moreover,  the  personal  appearance  will 
be  improved. 

Should  both  eyes  be  operated  upon  at  the  same  time  in  cases  of 
double  cataract  ?  It  is  doubtless  safer  to  operate  only  on  one  eye  at  a 
.  time.  Unsuspected  peculiarities  in  the  constitution  or  the  temperament 
may  show  themselves  in  the  course  of  the  treatment,  a  prior  knowledge 
of  which  may  prove  of  great  value  in  the  treatment  of  the  other  eye,  and 
lead  us,  perhaps,  to  select  a  different  mode  of  operation.  On  the  other 
hand,  it  has  been  urged  that  it  is  very  rare  to  see  a  bad  result  (e.g., 
suppuration  of  the  cornea)  in  both  eyes,  if  they  have  been  operated 
upon  at  one  sitting.  In  this  point  we  raust  be  much  guided  by  personal 
circumstances.  It  may  be  very  inconvenient  for  the  patient  to  have  the 
operations  divided,  and  the  treatment  thus  extended  over  a  long  period  ; 
or,  if  he  be  in  a  weak  and  nervous  condition,  it  may  be  unwise  to  submit 
him  to  the  anxiety  of  two  operations.  If  one  cataract  is  mature  and  the 
other  only  partially  formed,  but  yet  sufficiently  opaque  to  prevent  the 
patient  from  following  his  customary  employment,  it  may  be  necessary  to 
operate  upon  the  former,  so  as  to  enable  him  speedily  to  resume  his 


CATARACT.  231 

avocations  whilst  the  othci"  is  advancing  to  maturity.     If  no  such  neces- 
sity exists,  we  generally  wait  till  both  cataracts  are  mature. 

It  is  of  little  consequence  at  what  time  of  the  year  extraction  is 
performed.  Formerly  it  was  thought  advisable  to  ojjerate  chiefly  in  the 
s2H'ing  and  early  summer,  but  we  now  operate  all  the  year  round,  except 
during  intensely  hot  or  very  cold  weather,  for  extremes  of  temperature 
ai'c  not  favourable  for  the  progress  of  the  case.  If  the  weather  is  hot  and 
oppressive,  the  patients  become  very  restless,  irritable,  and  exhausted. 
The  time  of  day  is  also  of  little  or  no  moment,  although  I  myself 
prefer  the  morning,  for  we  can  then  judge  by  the  evening  whether  or 
not  any  primary  inflammatory  reaction  is  likely  to  set  in,  and  if  so,  we 
can  without  loss  of  time  endeavour  to  check  it. 

Before  an  operation  is  decided  upon,  the  general  health  must  be 
examined,  and  if  this  be  at  all  impaired  we  must  endeavour  to  improve 
it  as  much  as  possible  prior  to  operating.  It  is  of  the  greatest  advan- 
tage for  the  result  of  the  operation  to  have  the  patient  in  perfect  health. 
The  chief  fear  is,  that  in  a  weak  and  decrepid  person  the  vitality  of  the 
cornea  may  be  so  low  that  its  healing  power  is  greatly  impaired,  or  that 
it  may  even  slough  after  the  operation.  A  symptom  of  some  importance, 
as  being  indicative  of  this  low  vitality,  is  the  loss  of  elasticity  of  the 
skin,  so  that  if  we  pinch  up  a  fold  of  skin  on  the  back  of  the  hand  it  does 
not  fall  back  at  once,  but  remains  wrinkled.  Severe  cough  or  chronic 
bronchitis  contra-indicate  flap  extraction.  If  double  cataract  occurs  in 
youth  or  early  middle  age  (before  the  age  of  45),  and  if  its  formation 
is  rapid,  we  must  examine  whether  the  patient  is  suffering  from  diabetes, 
for  this  is  a  not  unfrequent  cause  of  cataract.  The  lens  becomes  affected 
chiefly  in  the  later  stages  of  the  disease,  when  the  health  is  much 
broken.  The  cataract  is  generally  softish,  and  its  formation  rapid.  In 
old  persons  a  more  or  less  large  and  hard  nucleus  will  be  present,  but 
diabetic  cataract  does  not  show  any  special  characteristics.  If  diabetes 
is  found  to  exist,  especial  care  must  be  taken  to  examine  the  sight  and 
the  field  of  vision,  as  affections  of  the  retina  and  optic  nerve  not  un- 
frequently  occur  in  the  course  of  the  disease,  and  may  therefore  co-exist 
with  the  cataract  and  render  the  prognosis  of  the  result  of  an  operation 
unfavourable. 

The  general  condition  of  the  eye  should  always  be  carefully 
examined  before  an  operation  for  cataract  is  determined  upon.  The 
tension  of  the  eyeball,  the  degree  of  sight,  and  the  state  of  the  field  of 
vision  must  be  ascertained,  so  that  the  presence  of  any  deep-seated 
lesion  may  not  escape  detection.  Otherwise  we  might  fall  into  the  re- 
prehensible and  unjustifiable  error  of  operating  upon  an  amaurotic  eye. 

Should  the  patient  be  suffering  from  epiphora,  dependent  upon  some 
affection  of  the  lachrymal  apparatus,  or  from  inflammation  of  the  eyehds 
or  the  conjunctiva,  this  should,  if  possible,  be  cured  prior  to  the  opera- 


232  DISEASES   OF   THE   CRYSTALLINE  LENS. 

tion,  as  any  such  complication  not  only  enhances  the  difficulties  of  the 
after-treatment,  but  may  even  endanger  the  result  of  the  operation. 

The  method  to  be  pui'sued  in  examining  the  perception  of  light  and 
the  condition  of  the  field  of  vision,  in  a  person  affected  with  mature 
catai'act,  has  been  already  explained  in  the  Introduction  (p.  8).  Such 
a  person  should  be  able  to  distinguish  a  low  burning  lamp  at  a  distance 
of  10  or  14  feet,  if  his  perception  of  light  is  good,  and  there  is  no  lesion 
of  the  deeper  tunics  of  the  eye.  If  there  is  any  marked  deterioration 
of  the  perception  of  light,  or  of  the  field  of  vision,  the  history  of  the 
case  must  be  carefully  inquired  into,  in  order  that  we  may  detect  the 
presence  of  any  complication.  If  the  upper  or  lower  half  of  the  field 
is  lost,  we  must  suspect  detachment  of  the  retina ;  if  the  lateral  halves 
are  wanting,  an  affection  of  the  optic  nerves.  Cerebral  amaurosis 
generally  causes  a  concentric  contraction  of  the  field,  or  the  latter  may 
commence  at  the  temporal  side.  In  glaucoma  the  contraction  of  the 
field  begins  almost  invariably  at  the  nasal  side.  If  such  a  contraction 
of  the  field  exists,  the  tension  of  the  eyeball  must  be  ascei'tained,  and 
the  other  symptoms  of  glaucoma  searched  for.  If  glaucoma  attacks  an 
eye  affected  with  mature  senile  cataract,  the  glaucoma  m.ust  first  be 
cured  by  an  iridectomy,  and  then  subsequently,  at  the  interval  of 
several  months,  the  cataract  should  be  removed.  But  this  must  not  be 
done  until  all  symptoms  of  irritation  and  increased  tension  have  sub- 
sided, and  the  improvement  in  the  nutrition  and  circulation  of  the  eye 
has  been  firmly  re-established.     (Vide  the  article  on  "  Glaucoma  "). 

The  pupil  should  be  dilated  by  atropine  before  the  operation.  In 
a  very  presbyopic  eye,  with  an  exceedingly  shallow  anterior  chamber, 
there  is  always  some  danger,  even  to  an  expert  operator,  of  wounding 
the  iris  either  before  the  counter-puncture  is  made,  or  whilst  the  flap  is 
being  formed.  Wide  dilatation  of  the  pupil  is  the  best  safeguard 
against  such  a  danger,  for  the  iris  will  be  removed  out  of  the  way  of 
the  puncture,  the  counter- puncture,  and  the  line  of  incision.  When  the 
aqueous  humour  flows  off,  the  pupil  again  contracts  somewhat ;  but  this 
will  not  be  of  much  consequence,  as  the  section  should  by  this  time  be 
nearly  completed.  The  degree  and  rapidity  with  which  the  pupil 
dilates  under  the  influence  of  atropine  also  affords  us  a  hint  as  to  the 
probability  of  iritis.  Von  Graefe  has  called  attention  to  the  fact  that  if 
the  iris  is  easily  and  quickly  affected  by  atropine,  there  is  less  tendency 
to  subsequent  iritis  than  if  its  action  is  tardy  and  imperfect. 

The  patient  should  be  operated  upon  in  the  recumbent  position, 
being  placed  either  on  a  couch  or  in  his  bed.  In  the  Hospital  I  prefer 
operating  in  the  ward,  as  there  is  considerable  risk  of  the  dressing 
being  disturbed  in  the  removal  of  the  patient  from  the  operating 
theatre.  The  light  should,  if  possible,  come  from  the  side,  for  this 
dazzles  the  patient  less,  and  causes  much  less  reflection  upon  the  cornea 


FLAP  EXTRACTION.  283 

than  when  it  comes  from  the  foot  of  the  bed  or  from  a  skylight.  The 
latter,  indeed,  is  the  worst  light  of  all  for  eye  operations,  moi'e  especially 
those  of  a  very  delicate  nature. 

The  position  which  the  operator  is  to  assume  with  regard  to  the 
patient  will  depend  upon  which  eye  is  to  be  operated  on,  and  upon  the 
fact  whether  the  surgeon  is  ambidexter  or  not.  Some  think  it  a  sine 
qua  noti  that  an  ocuHst  should  be  able  to  use  both  hands  equally  well ; 
but  this  is  not  the  case.  By  changing  his  position,  he  may  always 
operate  with  the  right  hand  upon  either  eye,  either  by  the  upper  or 
lower  section.  Yet  I  strongly  advise  every  surgeon  to  practise  operating 
with  the  left  hand,  for  he  will  constantly  j&nd  it  a  great  advantage  to  be 
able  to  use  it  well.  For  instance,  in  performing  iridectomy  it  is  very 
desii'able  that  he  should  be  able  to  grasp  the  iris  with  the  forceps  held 
in  the  left  hand,  and  snip  it  off  with  the  scissors  in  the  right,  or  vice 
versa.  Still,  if  he  finds  after  much  practice  on  the  dead  subject,  that  he 
cannot  operate  for  extraction  nearly  so  well  with  the  left  hand  as  with 
the  right,  he  should  not  endanger  the  result  of  the  operation  by  using 
the  left  hand.  If  the  left  eye  is  to  be  operated  on  (either  by  the 
upper  or  lower  section),  the  surgeon,  if  he  is  not  ambidexter,  is  to  seat 
himself  on  the  couch  in  front  of  the  patient,  and  on  his  left  side.  If  he 
operates  with  his  left  hand,  he  will  stand  behind  the  patient.  The 
latter  position  is  also  to  be  assumed  when  the  right  eye  is  to  be  ope- 
rated on. 

4.— FLAP  EXTRACTION". 

The  section  may  be  made  either  upwards  or  do'ViTiwards,  as  the  ad- 
vantages are  pretty  evenly  balanced.  The  downward  section  is,  however, 
the  easier  of  the  two.  There  is  often,  raoreover,  an  uncontrollable 
tendency  for  the  eye  to  roll  upwards  beneath  the  lid,  w^iich  materially 
enhances  the  difficulties  of  the  operation,  and  may  greatly  embarrass 
the  operator,  especially  during  the  laceration  of  the  capsule  and  the 
exit  of  the  lens.  The  chief  advantages  of  each  mode  of  operating 
may  be  briefly  stated  to  be  as  follows : — In  favour  of  the  upper  sec- 
tion, it  may  be  urged  that  the  broad  smooth  surface  of  the  inside  of 
the  upper  lid  will  lie  in  contact  wnith  the  section  and  support  it,  and 
thus  facilitate  the  union ;  whereas  the  edge  of  the  lower  lid  may  rub 
against  the  lips  of  the  incision,  or  even  get  between  them,  set  up  con- 
siderable irritation,  and  prevent  the  union  by  fii'st  intention.  Again,  if 
in  the  upper  section  the  wound  does  not  unite  by  first  intention,  either 
from  the  occurrence  of  prolapse  of  the  iris,  or  suppuration  of  the  edge 
of  incision,  the  cicatrix  thus  produced  will  be  hidden  by  the  upper  lid. 
But  to  this  it  may  be  objected,  that  if  the  prolapse  has  produced  much 
distortion  of  the  pupil,  the  latter  may  be  so  much  covered  by  the  upper 
lid  as  gTeatly  to  impair  the  vision  ;  so  that  it  will  be  necessary  to  make 


234  DISEASES   OF   THE   CRYSTALLINE  LENS. 

an  artificial  pupil  in  another  direction.  The  advantages  offered  by  the 
lower  section  are,  that  it  is  more  easy  of  performance  ;  as  are  also  the 
division  of  the  capsule,  the  exit  of  the  cataract,  and  the  removal  of  the 
remains  of  cortical  substance.  The  cornea  is,  moreover,  less  liable  to 
be  bruised,  and  should  suppui'ation  of  the  cornea  occur,  it  is  more 
likely  to  limit  itself  than  in  the  upper  section.  Bearing  these  points  in 
mind,  I  should  advise  the  beginner  at  first  to  perform  the  lower  section, 
until  he  has  acquii'ed  sufiicient  dexterity  and  experience  in  operating 
to  give  each  method  a  fair  trial. 

The  instruraents  required  for  flap  extraction  are — 1.  An  extraction 
knife.  2.  A  pair  of  forceps  for  fixing  the  eyeball.  3.  A  pricker  or 
Graefe's  cystotome,  for  dividing  the  capsule.  4.  A  curette,  which,  for 
convenience  sake,  is  fixed  to  the  other  end  of  the  pricker.  5.  A  blunt- 
pointed  secondary  knife.     6.   A  blunt-pointed  pair  of  scissors. 

Various  forms  of  extraction  knives  are  recommended  by  different 
operators.     I  myself  prefer  Sichel's  knife  (fig.  28).     It  is  rather  long 

Fig.  28. 


and  narrow,  and  increases  regularly,  but  not  too  abruptly,  from  point 
to  heel,  so  that  the  flap  is  formed  by  simply  pushing  the  blade  on 
through  the  anterior  chamber  until  the  section  is  completed.  Its  wedge 
shape  fills  up  the  gap,  and  prevents  the  premature  escape  of  the  aqueous 
humour.  The  handle  is  to  be  lightly  held  between  the  thumb,  fore,  and 
middle  finger,  the  thumb  being  slightly  bent  outwards  at  the  joint.  The 
elbow  must  be  kept  close  to  the  side  and  the  A\a'ist  steady,  so  that  all 
movements  are  made  from  the  fingers  and  hand. 

I  will  now  proceed  to  a  description  of  the  operation,  and  I  shall 
throughout  suppose  that  the  right  eye  is  to  be  operated  upon  by  the 
upper  section. 

I  shall  enter  somewhat  at  length  into  the  description  of  the  mode  of 
operating,  the  accidents  which  may  occur,  and  the  principles  which 
should  guide  us  in  the  after  treatment,  because  most  of  these  questions 
are  of  importance  in  every  mode  of  operating  for  the  extraction  of 
cataract ;  hence  it  is  absolutely  necessary  that  the  surgeon  should  be 
acquainted  with  them,  even  although  he  may  entirely  abandon  the 
common  flap  extraction  for  Von  Graefe's  new  operation. 

The  operator  should  stand  or  sit  behind  the  patient,  who  is  to  be 
placed  in  the  recumbent  position.  If  he  is  about  to  operate  without 
fixation,  he  will  hold  the  upper  eyelid  with  the  forefinger  of  his  left  hand, 
drawing  it  upwards  and  away  from  the  eye.  The  tip  of  the  second 
finger  is  to  be  placed  gently  against  the  sclerotic  on  the  nasal  side  of 


FLAP  EXTRACTION.  235 

the  cornea,  so  as  to  prevent  the  eye  from  rolling  too  far  inwards.  An 
assistant  is  to  draw  the  lower  eyelid  down  without  everting  it.  Many 
of  our  best  operators  do  not  employ  fixation,  and  generally  make  ad- 
mii'able  sections  ;  but  yet  cases  will  occur  in  which  even  the  most  skilled 
operator  does  not  make  the  counter-puncture  just  at  the  desired  point. 
The  chief  difficulty  in  operating  without  fixation  is,  that  the  eye  may 
roll  swiftly  inwards  directly  the  puncture  is  made,  or  even  before,  so 
that  the  cornea  becomes  almost  hidden  in  the  inner  canthus,  and  the 
knife  has  to  traverse  the  anterior  chamber  and  to  make  the  counter- 
puncture  without  the  operator  being  able  to  see  its  course.  This  will 
prove  extremely  cmbain-assing  to  the  beginner,  and  may  even  unnerve 
him  for  the  remainder  of  the  operation.  I  should,  therefore,  strongly 
recommend  him  to  fijt  the  eyeball,  as  this  greatly  facilitates  the  first 
part  of  the  operation,  and  as  there  is  not  the  slightest  objection  to  his 
doing  so.  It  has  been  objected  that  the  fixation  often  produces  pain 
and  much  irritation,  but  this  will  hardly  occui",  if  it  be  gently  and  care- 
fully done.  Moreover,  so  sensitive  an  eye  would  prove  most  difficult  to 
operate  upon  without  fixation.  Afterwards,  when  the  operator  has 
gained  more  confidence  and  dexterity,  he  may  do  without  it,  if  he 
chooses.  Various  instruments  have  been  devised  for  this  purpose,  but 
the  common  eye  forceps  are  the  best.  Their  use  in  this  operation  has 
long  been  advocated  by  Von  Graefe,  and  more  lately  by  Mr.  France. 
As  soon  as  the  counter- puncture  is  made,  they  are  to  be  removed,  for  the 
eye  is  then  completely  under  our  control.  The  operator  should  rather 
fix  the  eye  himself  than  entrust  this  to  an  assistant,  for  it  is  impossible 
that  their  hands  can  work  together  with  such  unanimity  as  if  both 
hands  are  guided  by  the  same  volition.  If  fixation  be  employed,  an 
assistant  must  hold  the  lids.  If  the  right  eye  is  to  be  operated  on,  he 
should  stand  on  the  left  side  of  the  patient,  and  place  the  tips  of  the 
fore  and  second  finger  of  his  right  hand  upon  the  edge  of  the  upper  lid 
(without  touching  the  lashes),  and  draw  it  gently  upwards  and  a  little 
inwards,  away  from  the  eyeball.  If  the  lids  are  at  all  moist,  a  piece  of 
linen  may  be  folded  around  the  fingers,  so  as  to  prevent  their  slipping. 
The  lower  lid  is  to  be  held  with  the  forefinger  of  his  left  hand.  But  if 
the  assistant  is  not  dexterous  and  trustworthy,  and  the  surgeon  cannot 
operate  well  without  fixation,  the  spring  speculum  may  be  employed 
to  keep  the  lids  apart,  but  I  am  rather  afraid  of  it,  as  it  is  apt  to 
irritate  the  eye,  and  to  press  upon  the  eyeball. 

The  operation  is  divided  into  three  periods — 1st.  The  formation 
of  the  flap  ;  2nd.  The  laceration  of  the  capsule  ;  3rd.  The  removal  of 
the  lens. 

First  Period. — Let  us  again  assume  that  the  right  eye  is  to  be 
operated  upon  by  the  upper  section,  and  that  the  operator  will  fix  the 
eye.     Holding  the  forceps  in  his  left  hand,  he  seizes  a  fold  of  coujunc- 


236 


DISEASES   OP   THE   CRYSTALLINE  LENS. 


tival  and  subconjunctival  tissue  near  tlie  lower  edge  of  the  cornea  (as 
in  Fig.  29,  after  France),  or,  as  I  prefer  it,  rather  more  to  the  nasal  side, 
and  draws  the  eyeball  gently  down,  so  as  to  bring  the  cornea  well  into 
view.     Then,  holding  the  knife  lightly  in  his  right  hand,  and  steadying 

the  latter  by  placing  his  ring 
or  little  finger  against  the 
temple,  he  enters  the  point  at 
the  outer  side  of  the  cornea 
about  a  quarter  of  a  Hne  from 
its  edge,  and  just  at  its  trans- 
verse diameter,  and  then  car- 
ries the  blade  steadily  and 
rather  slowly  across  the  ante- 
rior chamber  to  the  point  of 
counter-puncture,  keeping  it 
quite  parallel  to  the  iris.  Spe- 
cial care  must  be  taken  not  to 
rotate  it  or  to  press  upon  its 
edge,  but  rather  to  press  upon 
the  back  of  the  blade,  as  if,  in  fact,  he  were  wishing  to  cut  with 
this.  If  this  be  done,  the  blade  will  be  pushed  steadily  on  and  fill  up 
the  gap,  thus  preventing  the  premature  escape  of  the  aqueous  humour. 
I  find  this  pressing  upon  the  back  of  the  blade  one  of  the  most  difficult 
things  for  the  young  operator  to  acquire.  The  eye  of  the  operator  is 
not  to  be  kept  fixed  upon  the  point  of  the  knife,  but  upon  the  point 
where  he  wishes  to  make  the  counter-puncture,  for  this  will  insure  the 
knife  being  brought  out  at  the  desired  spot,  which  should  lie  slightly 
in  the  upper  half  of  the  cornea,  about  a  quarter  of  a  line  from  its  edge. 
As  soon  as  the  counter-puncture  is  made,  the  forceps  are  to  be  removed 
and  the  handle  of  the  knife  turned  back  towards  the  temple,  the  blade 
being  pushed  steadily  on  until  the  section  is  all  but  finished.  When 
only  a  small  bridge  of  cornea  remains  undivided,  the  section  is  to  be 
slowly  completed  by  turning  the  edge  of  the  knife  a  little  forwards,  and, 
instead  of  carrying  it  straight  on,  drawing  it  back  from  heel  to  point 
until  the  section  is  finished.  Von  Graefe  insists  especially  upon  the 
advantage  of  doing  this,  for  as  the  narrowest  part  of  the  blade  thus 
issues  last  from  the  incision,  the  flap  will  be  less  elevated  than  by  the 
broad  part ;  moreover,  the  altered  position  and  direction  of  the  knife 
cause  a  relaxation  in  the  tension  of  the  muscles  of  the  eye,  and  thus 
diminish  straining.  When  the  incision  is  completed,  the  upper  lid  is 
to  be  gently  and  carefully  dropped,  so  that  it  may  not  catch  in  between 
the  lips  of  the  wound  and  evert  the  flap.  The  patient  having  been 
calmed  by  a  few  words  of  encouragement,  we  pass  on  to  the 

Second  Feriod,  the  Oyenhuj  of  tlie  Capsule. — This  may  be  done  either 


FLAP  EXTRACTION. 


237 


with  tlie  pricker  (Fig.  30,  wliicli  represents  this  instrument,  together 
with  the  curette,  which  is  phiced  at  the  other  end  of  the  handle),  or 
with  Graefe's  cystotome.  The  patient  is  directed  to  look  well  down  to 
his  feet,  and  the  upper  Hd  being  slightly  lifted,  the  pricker  is  introduced 


Fi£.  30. 


Fig.  31. 


with  its  blunt  angle  downwards.  When  arrived  at  the 
inner  side  of  the  pupil,  it  is  slightly  rotated,  so  as  to  tui'n 
its  point  against  the  capsule,  which  is  to  be  divided 
across  as  far  as  the  outer  edge  of  the  pupil  by  one  or 
more  incisions.  The  point  is  then  turned  downwards, 
and  the  instrument  carefully  removed,  so  as  not  to 
entangle  it  in  the  iris  or  cornea.  For  flap  extraction  I 
prefer  Graefe's  cystotome  (Fig.  31 — beside  it  is  an 
enlarged  vieAv),  as  it  makes  a  freer  opening,  and  as  we 
need  not  change  its  horizontal  position  in  lacerating  the 
capsule,  whereas  the  handle  of  the  pricker  requires  to 
be  a  little  elevated,  which  causes  more  or  less  gaping  of 
the  section.  Care  must  be  taken  not  to  press  the  point 
of  the  pricker  or  cystotome  against  the  lens  in  dividing 
the  capsule,  otherwise  we  may  cause  a  displacement  of 
the  lens  into  the  vitreous  humour. 

Third.  Period — Removal  of  the  Lens. — The  patient 
being  again  directed  to  look  downwards,  the  point  of 
the  forefinger,  or  the  end  of  the  curette,  is  to  be  placed 
against  the  lower  lid,  and  a  gentle,  but  steady,  pressure 
made  upon  the  globe.  The  point  of  the  other  forefinger 
may  be  placed  on  the  upper  portion  of  the  eyeball,  so  as 
to  regulate  and  alternate  the  pressure  to  a  nicety.  The 
pressure  on  the  lower  lid  should  be  at  first  backward,  in 
order  that  the  upper  edge  of  the  lens  may  be  tilted 
slightly  forward  against  the  upper  portion  of  the  pupil, 
which  gradually  dilates  and  permits  the  presentation  of 
the  lens.  The  pressure  is  then  directed  a  little  more  upwards  and  back- 
wards, so  that  the  lens  advances  through  the  pupil  into  the  anterior 
chamber,  and  makes  its  exit  through  the  incision.  If  it  halts  a  little  in 
its  course  through  the  section,  it  may  be  extracted  with  the  curette.  The 
pressure  throughout  should  be  steady,  but  very  gentle,  in  order  that  the 
lens  may  not  be  violently  jerked  out,  which  is  generally  accompanied  by 


238  DISEASES  OP   THE  CRYSTALLINE  LENS. 

rupture  of  the  hyaloid  membrane  and  an  escape  of  vitreous  humour. 
When  the  lens  has  been  removed,  we  should  examine  its  outline  to  see 
■whether  this  is  perfect,  or  whether  it  is  irregular  or  notched,  as  the 
latter  shows  at  once  that  portions  of  the  cortical  substance  have 
remained  behind.  If  the  cataract  is  not  quite  mature,  fragments  of 
cortex  are  apt  to  remain  in  the  capsule,  or  are  stripped  off  dm'ing  the 
passage  of  the  lens  through  the  pupil  or  the  corneal  incision,  to  either 
of  which  they  may  cling.  These  portions  should,  if  possible,  be  removed, 
as  they  are  very  apt  to  set  up  iritis  or  to  give  rise  to  secondary  cataract. 
The  lids  are,  therefore,  to  be  closed  and  lightly  rubbed  in  a  circular 
direction,  so  that  any  little  flakes  remaining  behind  the  iris  may  be 
brought  into  the  area  of  the  pupil,  whence  they  are  to  be  gently  re- 
moved with  the  curette,  as  also  any  portions  adhering  to  the  lips  of  the 
wound.  The  vision  of  the  patient  may  also  be  tested  by  trying  if  he 
can  count  fingers,  and  if  it  is  not  as  good  as  might  be  expected,  we  may 
examine  again  as  to  whether  remnants  of  lens  substance  still  linger 
behind. 

We  must  now  briefly  consider  what  course  is  to  be  pursued  if  any 
untoward  circumstances  arise  during  the  different  steps  of  the  opera- 
tion. 

Under  the  following  circumstances,  it  is  advisable  to  withdraw  the 
knife  at  once,  and  to  postpone  the  operation  until  the  wound  is  united  : — 
1.  If  the  puncture  is  too  near  the  edge  of  the  cornea,  or  in  the  scle- 
rotic. 2.  If  it  is  too  far  in  the  cornea,  so  that  the  flap  would  be  too 
small.  3.  If  the  aqueous  humour  spirts  out  when  the  point  of  the 
knife  has  only  just  entered  the  anterior  chamber,  for  the  iris  will  then 
fall  forward  upon  the  knife,  which  would  become  entangled  in  it,  so 
that  it  would  be  impossible  to  finish  the  section  without  lacerating  the 
iris  considerably.  4.  If  the  point  of  the  knife  is  so  blunt  that  it  will 
not  readily  make  the  counter- puncture. 

Should  the  aqueous  humour  escape  directly  the  counter-puncture 
has  been  made,  the  section  may  yet  be  finished  without  wounding  the 
iris,  by  placing  the  point  of  the  fore  or  middle  finger  of  the  other  hand, 
upon  the  edge  of  the  blade,  and  pushing  the  iris  off  from  it  as  the 
section  is  being  slowly  completed.  If,  however,  it  is  impossible  to 
avoid  wounding  the  iris,  it  is  better  to  cut  boldly  through  it,  as  this  is 
far  less  apt  to  excite  iritis  than  if  the  knife  becomes  entangled  in  it.  If 
the  counter-puncture  is  too  close  to  the  sclerotic,  the  knife  must  be 
slightly  drawn  back,  and  another  counter-puncture  made,  or  the  size  of 
the  section  be  diminished  by  turning  the  edge  of  the  blade  slightly 
forwards  in  finishing  the  flap.  This  should  also  be  done  when  the 
counter- puncture  is  too  low.  If  it  be  too  high,  the  flap  will  be  too  small, 
and  this  may  be  remedied  (1)  by  making  another  counter- puncture  a 
little  lower  down,  (2)  by  turning  the  edge  of  the  blade  back  in  cutting 


FLAP   EXTRACTION. 


239 


out,  or  (3)  by  enlarging  the  section  downwards  with  a  secondary  knife  or 
a  pair  of  blunt-pointed  scissors.  The  last  proceeding  is  to  be  preferred  if 
the  counter- puncture  is  much  too  high.  If  we  purpose  doing  this,  the  sec- 
tioii  is  to  be  continued  until  only  a  little  bridge  of  cornea  is  left  standing 
(Fig.  32,  a).  The  knife  is  then  to  be  withdrawn,  and  the  section  enlarged 
by  dividing  the  cornea  to  the  required  extent  at  the  counter-puncture 
with  the  probe-pointed  secondary  knife  (Fig.  33),  or  with  a  pairofblunt- 

Fk.  32.  Fiir.  33. 


pointed  scissors.  The  advantage  of  leaving  the  little  bridge  standing 
is,  that  it  will  keep  the  cornea  tense,  and  prevent  its  yielding  before  the 
knife  or  scissors.  The  bridge  is  then  to  be  divided,  or  before  so  doing 
the  capsule  may  be  opened.  The  size  of  the  flap  should  always  be 
noted  before  the  section  is  completed,  so  that  we  may  enlarge  it  in  the 
above  manner  if  necessary.  If  the  section  is  too  small  to  permit  the 
ready  exit  of  the  lens,  there  is  much  danger  of  rupture  of  the  hyaloid 
membrane  and  escape  of  vitreous  humour,  and  of  bruising  of  the  iris  and 
cornea.  It  is  also  advisable  to  leave  the  bridge  standing  if  the  patient 
is  very  unruly,  and  strains  greatly  as  we  are  making  the  section.  A 
few  moments'  rest  will  generally  sufiice  to  restore  his  quietude,  and 
then  the  bridge  may  be  divided. 

If  the  lens  does  not,  at  the  third  period,  readily  present  itself  in  the 
pupil,  we  must  on  no  account  attempt  to  force  this  by  pressing  strongly 
on  the  eye ;  but  we  must  lacerate  the  capsule  again,  and  more  freely 
than  before.  If  the  capsule  be  so  tough  as  not  to  be  readily  torn  with 
the  cystotome,  it  sometimes  comes  away  with  the  lens,  or  it  may  be 
divided  with  the  point  of  the  knife,  or  be  afterwards  removed  with  a 
hook  or  a  pair  of  iris  forceps. 

If  a  little  vitreous  humour  escapes  with  the  lens,  it  is  but  of  slight 
consequence.  The  protruding  portion  is  to  be  snipped  off,  and  a  firm 
compress  apphed.     But  it  is  very  different  if  it  escapes  before  the  lens, 


240  DISEASES  OP  THE  CRYSTALLINE  LENS. 

for  then  it  will  push  the  latter  aside,  so  that  it  may  even  fall  to  the 
bottom  of  the  vitreous  humour.  If  this  accident  should  occur,  a  hook 
or  scoop  should  be  passed  behind  the  lens,  and  the  latter  gently  "  fished 
out."  It  should  be  extracted  at  all  hazards,  for  if  it  remains  behind  it  is 
but  too  likely  to  set  up  a  most  destructive  and  painful  panophthalmitis. 

After  the  exit  of  the  lens,  the  corneal  flap  sometimes  becomes 
wrinkled  and  collapsed,  so  that  it  falls  away  from  the  line  of  incision. 
This  wrinkling  is  due  either  to  decrease  of  the  intra-ocular  tension,  or 
to  a  dim.in.ution  in  the  elasticity  of  the  cornea.  Von  Graefe  lays  great 
stress  upon  the  importance  of  this  symptom,  considering  it  unfavourable 
if  the  collapse  be  at  all  considerable,  for  he  has  found  that  suppuration 
of  the  cornea  often  occurs  in  such  cases.  If  we  therefore  find,  in  a  case 
of  double  cataract  which  is  to  be  operated  on  at  one  sitting,  that  the 
cornea  of  the  first  eye  becomes  much  wrinkled  after  extraction,  it  would 
be  wise  to  submit  the  other  eye  to  a  different  mode  of  operation.  In 
such  cases,  also,  great  care  must  be  taken  that  the  flap  is  not  turned 
back  when  the  upper  lid  is  let  down.  If  the  iris  protrudes  between 
the  lips  of  the  wound  after  removal  of  the  lens,  or  if  the  pupil  is  dis- 
torted, the  lids  should  be  closed  and  lightly  rubbed  in  a  circular  direc- 
tion, so  as  to  replace  the  iris,  and  restore  the  regularity  of  the  pupil. 
If  the  prolapse  still  persists,  it  may  be  gently  replaced  with  the  curette. 
But  if  all  our  efforts  prove  unavailing,  it  is  by  far  the  best  course  to 
draw  it  out  a  little  further  and  snip  it  off.  The  iridectomy  will  not  be 
of  the  slightest  disadvantage,  more  especially  in  the  upper  section  ;  in 
fact,  it  may  prove  of  positive  advantage,  not  only  in  favouring  the  cure, 
but  also  in  exposing  remnants  of  lens  substance  which  may  be  situated 
behind  the  iris,  and  have,  perhaps,  caused  the  prolapse ;  whereas  the 
occurrence  of  prolapse  after  extraction  is  one  of  the  chief  dangers  and 
annoyances  of  this  operation.  The  protruding  portion  of  iris  sets  up 
considerable  irritation,  and  prevents,  perhaps,  the  union  of  the  section, 
the  aqueous  humour  flowing  off  through  the  fistulous  opening ;  and  this 
constant  irritation  may  set  up  iritis  or  irido-cyclitis.  Even  if  the  iris 
unites  with  the  section,  a  broad  unsightly  cicatrix  will  be  left,  the  pupil 
being,  perhaps,  greatly  distorted  or  almost  obliterated.  To  prevent  all 
these  untoward  complications,  I  strongly  advise  the  removal  of  a  portion 
of  the  iris  if  the  prolapse  cannot  be  easily  returned,  or  if  the  iris  has 
been  much  contused  by  the  exit  of  the  lens,  or  by  our  endeavours  to 
restore  the  prolapsed  portion. 

Hoomorrhage  into  the  vitreous  humour  is  a  disastrous  occurrence. 
It  may  take  place  either  at  the  time  of  the  operation,  or  some  hours 
afterwards.  The  patient  complains  of  a  sudden  sharp  pain,  a  gush  of 
vitreous  takes  place,  followed  by  blood,  and  the  eye  is  lost.  In  such 
cases  there  generally  exists  a  diseased  condition  of  the  choroidal  and 
retinal  vessels,  detachment  of  the  retina,  etc. 


FLAP  EXTRACTION.  241 

The  after  treatment  of  flap  extraction  is  a  subject  of  great  importance, 
as  much  may  be  done  by  timely  care  and  attention.  As  it  is  of  con- 
sequence to  detect  and  combat  any  unfavourable  symptoms  at  the  earliest 
stage,  the  surgeon  should  visit  the  patient  very  frequently  during  the 
first  few  days  after  the  operation,  and,  if  possible,  himself  change  the 
dressings,  so  that  he  may  watch  the  condition  of  the  lids,  the  quantity 
and  character  of  the  discharge,  etc.  As  the  after-treatment  of  the 
different  operations  for  cataract  involves  the  same  principles,  I  shall  lay 
down  certain  broad  general  rules  of  treatment,  which  will,  however, 
require  modification  according  to  the  exigencies  of  particular  cases.  At 
one  time  the  antiphlogistic  treatment  was  in  great  repute.  Local  and 
general  depletion  were  had  recourse  to,  and  perhaps  repeated  several 
times,  upon  the  slightest  appearance  of  pain  or  inflammatory  symptoms. 
But  now  this  mode  of  treatment  has  justly  fallen  into  disuse.  Our 
primary  object  is  to  obtain  adhesion  of  the  corneal  flap  by  the  first  inten- 
tion, and  this  will  take  place  far  more  readily  in  a  strong  healthy  person, 
than  in  one  who  is  weak  and  decrepid ;  nearly  one-half  of  the  cornea 
has  been  divided,  and  for  a  time  the  other  half  has  to  carry  on  the  nutri- 
tion of  the  whole,  and  to  assist  in  the  process  of  union.  It  must  also  be 
remembered  that  this  operation  is  generally  performed  in  persons  above 
the  age  of  50  or  55,  and  even  indeed  in  the  very  aged,  whose  vital 
powers  "will  not  bear  depression.  The  general  health  and  the  reparative 
power  of  the  system  must  therefore  be  sustained.  The  better  and 
stronger  the  patient's  constitution  is,  the  more  favourable  may  be  the 
prognosis  of  the  result  of  the  operation.  Even  the  florid,  turgid, 
apoplectic- looking  individual  warrants  a  better  prognosis  than  the  very 
aged  decrepid  person,  whose  general  health  is  poor  and  feeble,  whose 
cheeks  are  pale  and  shrunken,  whose  arteries  are  rigid  and  skin  unelastic. 
Von  Graefe  also  considers  the  prognosis  less  favourable  if  the  eyeball 
is  deep-set  and  sunken,  and  the  diameter  of  the  cornea  vshort,  for  in  such 
cases  flaccidity  and  wrinkling  of  the  corneal  flap,  and  suppuration  of 
the  cornea,  are  of  not  unfrequent  occurrence  on  account  of  its  feeble 
nutrition. 

The  after  treatment  must  be  varied  according  to  the  general  health, 
constitution,  and  habits  of  the  patient.  The  diet  should,  from  the  com- 
mencement, be  light,  nutritious,  and  easily  digestible.  Meat  may  be 
allowed  once  daily ;  it  should,  however,  be  finely  minced,  so  that  there 
is  no  need  for  mastication,  which  would  disturb  the  quietude  of  the  eye. 
Good  beef  tea  or  mutton  broth  may  be  given  occasionally  during  the 
day,  but  slops  are,  as  a  rule,  to  be  avoided.  But  whilst  we  endeavour  to 
sustain  the  patient's  strength,  we  must  not  fall  into  the  opposite  error 
of  over-feeding  him.  In  a  very  plethoric  and  full-blooded  individual, 
especially  if  marked  inflammatory  and  febrile  symptoms  manifest  them- 
selves, a  strictly  antiphlogistic  regimen  must  be  observed.    With  regard 


242  DISEASES   OF   THE   CRYSTALLINE  LENS. 

to  stimulants  and  beer,  we  must  be  entirely  guided  by  the  patient's  con- 
stitution and  habits.  It  is  very  unwise  to  cut  off  all  stimulants  from 
an  individual  who  has  always,  and  perhaps  largely,  indulged  in  their 
use  ;  we  should  allow  him  a  moderate  amount  of  his  customary  beverage, 
watching  the  while  its  effect,  and  diminishing  or  increasing  the  quan- 
tity as  the  case  may  demand.  In  feeble,  decrepid  persons  stimulants 
and  malt  liquor,  together  with  a  good  nutritious  diet,  often  prove  of 
great  service ;  quinine  and  ammonia  being  also  given. 

It  is  well  to  administer  a  gentle  purgative  the  day  before  the  opera- 
tion, so  that  the  bowels  may  not  require  to  be  opened  for  a  day  or  two 
after  the  latter.  A  mild  dose  of  castor-oil  should  then  be  given, 
in  order  to  prevent  any  straining ;  and  this  may  be  repeated  if  neces- 
sary. 

When  the  operation  has  been  concluded,  the  patient  is  to  be  placed 
in  bed  in  a  darkened  room.  At  night  his  hands  should  be  tied  to  the 
side  of  the  bed,  to  prevent  his  touching  his  eyes  daring  sleep.  The 
lids  of  both  eyes  may  be  fastened  with  a  strip  or  two  of  sticking  plaister, 
although  this  is  apt  to  irritate  from  its  shrinking  and  hardening.  I 
myself  prefer  a  light  bandage,  especially  Liebreich's,  which  is  the  most 
convenient  for  this  purpose.  If  this  is  found  to  be  too  hot,  I  employ 
a  very  thin  gauze  bandage.  A  piece  of  soft  linen  is  to  be  applied  over 
the  eyelid  to  soak  up  any  discharge,  and  prevent  its  clogging  and 
hardening  the  charpie,  a  little  pad  of  which  is  to  be  next  applied,  the 
whole  being  kept  in  place  by  the  bandage.  But  if  we  desire  to  exert 
more  pressui-e  upon  the  eye,  we  must  employ  Von  Graefe's  compress 
bandage,  the  application  of  which,  however,  demands  far  more  care 
and  practice. 

So  much  care  and  attention  is  required  in  the  application  of  these 
bandages,  and  in  the  regulation  of  the  amount  of  pressure,  that  we  are 
but  seldom  able  to  entrust  this  to  a  nurse.  If  we  cannot  change  the 
compress  ourselves,  or  leave  this  duty  to  a  practised  and  trustworthy 
assistant,  it  is  far  better  to  abstain  altogether  from  its  use.  It  should 
be  changed  night  and  morning,  and,  if  the  eye  feels  uncomfortable, 
even  more  frequently.  The  quantity  and  character  of  the  discharge 
upon  the  linen  and  charpie^should  be  examined,  as  it  affords  a  clue  to 
the  condition  of  the  eye.  The  edges  of  the  lids  should  be  softly 
sponged  with  lukewarm  water,  so  as  to  remove  any  hardened  discharge 
from  the  eyelashes,  which  may  also  be  smeared  with  a  little  cold  cream 
or  simple  cerate.  This  will  prevent  their  sticking  togethei',  and  thus 
interfering  with  the  ready  escape  of  tears  or  discharge.  Great  care 
must,  however,  be  taken  not  to  rub  or  press  upon  the  upper  eyelid, 
otherwise  the  coaptation  of  the  flap  may  bo  disturbed  and  union 
prevented.  Much  comfort  and  relief  is  afforded  by  the  sponging 
and  cleansing  of  the  eyelids,  and  the  change  of  the  compress.     The 


FLAP  EXTRACTION.  243 

eye  should  not,  however,  be  opened  or  examined  unless  we  specially 
desire  to  ascertain  its  condition.  Union  of  the  flap  generally  takes 
place  within  the  first  forty-eight  houi'S,  or  even  sooner.  Then  it  is 
advisable  to  apply  a  drop  of  atropine  once  or  twice  daily  to  the  inside 
of  the  lower  lid,  without  widely  opening  the  eye.  This  soothes  the  eye 
and  dilates  the  pupil,  so  that  there  is  less  chance  of  a  secondary 
cataract,  as  the  torn  edges  of  the  caj)sule  have  no  point  to  adhere 
against,  and  will  therefore  retract  and  shi'ivel  up.  Moreover,  should 
iritis  occur,  it  will  be  of  great  advantage  to  have  the  pupil  already 
widely  dilated.  It  is  an  interesting  fact  that  if  atropine  was  applied 
before  the  operation,  its  effect  upon  the  pupil  partially  returns  when 
the  section  is  united,  and  the  aqueous  humour  re-accumulated.  Should 
the  atropine  cause  any  irritation,  a  solution  of  belladonna  should  be 
substituted.  A  few  hours  after  the  operation,  the  patient  generally 
experiences  a  slight  sensation  of  pressure  and  smarting  in  the  eye, 
which  lasts  for  a  few  minutes,  but  re-appears  at  intervals  of  an  hour  or 
two.  It  is  due  to  an  accumulation  of  tears  and  aqueous  humour.  If 
the  pain  increases  towards  night  and  becomes  continuous,  and  the  eye 
is  hot,  and  the  patient  restless  and  uncomfortable,  morphia  should  be 
administered  either  internally  or  endermically.  I  generally  employ  the 
subcutaneous  injection,  varying  in  strength  from  -g-th  to  ;jth  of  a  grain. 
It  may  be  repeated  if  necessary.  If  the  eye  is  very  hot  and  painful, 
much  relief  is  often  experienced  from  cold-water  compresses.  But 
their  use  requires  much  care  and  discretion,  for  if  they  are  applied  for 
too  long  a  time,  they  may  depress  the  circulation  of  the  part  too  much, 
and  thus  increase  the  danger  of  suppuration  of  the  cornea.  I  have 
also  sometimes  found  great  relief  from  the  application  of  two  or  three 
leeches  to  the  temple,  especially  in  plethoric  individuals.  I  must, 
however,  state  that  Von  Graefe,  after  having  for  many  years  employed 
leeches,  has  now  entirely  abandoned  their  use  during  the  first  three 
days  after  the  operation.  He  thinks  that  they  prove  injurious,  insomuch 
as  they  produce  in  the  first  instance  an  increased  congestion  of  the 
infiltrated  structures,  and  thus  favour  suppuration  of  the  edges  of  the 
wound.*  In  such  cases  he  tnuch  prefers,  if  the  patient  be  plethoric  and 
robust,  a  small  venesection  of  from  foiir  to  eight  ounces  ;  also  if  there  is 
much  pain  accompanied  by  considerable  laclirymation  and  swelling  of 
the  lids  during  the  first  thirty-six  hours  after  the  operation,  for  during 
this  period  suppurative  inflammation  generally  commences.  But  it  is 
not  to  be  employed  if  suppuration  has  already  set  in. 

If  the  case  goes  on  well,  without  the  appearance  of  any  unfavourable 
symptoms,  such  as  severe  pain  in  and  around  the  eye,  swelling  of  the 
lids,  muco-purulcnt  discharge,  or  copious  laclirymation,  the  eye  should 

*  Graefe's  Clinical  Lecture,  "  Kl.  Moiiatsbl.,"  1863,  translated  in  "  Ophthalmic 
Review,"  No.  3. 

R  2 


244  DISEASES   OF   THE   CRYSTALLINE   LENS. 

not  be  opened  dimng  the  first  five  or  six  days.  Nothing  is  so  bad  as 
being  too  curious  as  to  the  result,  and  opening  the  eye  too  early  to 
assure  ourselves  that  everything  is  going  on  well,  for  this  may  easily 
set  up  iritis.  It  is  very  dilFerent  if  unfavourable  symptoms  arise,  for 
then  it  is  best  to  open  the  lids  and  carefully  examine  the  condition  of 
the  eye,  so  that  we  may  know  what  is  really  the  matter,  and  what 
treatment  should  be  adopted.  The  upper  lid  should  be  gently  lifted, 
and  the  state  of  the  cornea  and  iris  examined.  This  is  best  done  by 
the  light  of  a  candle,  which  should  be  shaded  by  the  hand  of  the  nurse 
or  assistant  until  the  moment  that  the  surgeon  is  ready  to  examine  the 
eye.  In  this  way,  the  latter  is  exposed  only  for  a  few  seconds  to  the 
light,  and  the  glare  and  intensity  of  the  illumination  is  far  less  than  if 
daylight  is  admitted  into  the  room. 

But  the  case  may  not  run  so  favourable  a  course.  The  thinly 
cicatrised  wound  may  yield,  and  a  portion  of  the  iris  protrude  through 
it.  This  freqiTcntly  happens  a  few  days  after  the  operation.  The 
patient  experiences  a  feeling  of  grit  or  sand  in  the  eye,  as  if  a  foreign 
body  were  lodged  under  the  eyelid.  The  lids  become  swollen,  the  eye 
painful,  and  there  is  a  copious,  clear,  watery  discharge,  which,  after  a 
time,  assumes  more  of  a  muco-purulent  character.  These  symptoms 
may  arise  suddenly,  perhaps,  after  a  fit  of  coughing  or  sneezing,  which 
has  caused  the  section  to  yield.  If  the  prolapse  is  large,  and  causes  a 
wide  gaping  of  the  wound,  the  pain  and  irritation  are  often  very  great. 
The  eye  should  be  opened  and  the  real  condition  ascertained.  If  pro- 
trusion of  the  iris  has  occurred,  the  lids  must  be  gently  closed  again, 
and  a  firm  compress  applied,  which  will  not  only  favour  the  consolida- 
tion of  the  wound  by  the  formation  of  a  layer  of  lymph  over  the 
prolapse,  but  will  prevent  its  increasing  in  size,  and  by  the  continuance 
of  gentle  pressure  will  even  cause  it  to  shrink.  Afterwards,  when  the 
wound  is  quite  consolidated,  and  a  firm  layer  of  exudation  covers  the 
prolapse,  the  latter  may  be  pricked  with  a  fine  needle,  as  has  been 
recommended  by  Mr.  Bowman,  so  as  to  let  the  aqueous  humour,  which 
is  distending  it,  flow  off.  The  prolapse  then  shrinks  and  dwindles 
down.  This  pricking  may  be  repeated  several  times.  If  the  prolapse 
is  large  and  widely  distends  the  section,  it  may  be  necessary  to  remove 
it,  either  with  scissors  or  with  the  extraction  knife,  a  compress  being 
afterwards  applied.  Some  surgeons  touch  the  prolapse  with  a  stick  of 
nitrate  of  silver,  but  this  often  produces  great  irritation.  The  prolapse 
may  have  so  drawn  up  the  pupil  that  it  is  quite  covered  by  the  upper 
lid,  or  even  involved  in  the  section,  which  will  afterwards  necessitate 
the  formation  of  an  artificial  pupil,  and  this  will  often  also  cause  the 
prolapse  to  shrink.  Prolapse  of  the  iris,  occurring  after  extraction, 
is  not  only  a  source  of  long- continued  trouble  to  the  patient,  but  may 
even   prove  very    dangerous,   by  setting  up  protracted  inflammatory 


FLAP  EXTRACTION.  245 

complications — e.  cj.,  irido-clioroiditis — wLicli  may  eventually  destroy 
the  eye. 

But  still  moi'e  dangerous  is  the  occui'rence  of  suppuration  of  the 
cornea,  which  is  to  be  chiefly  feared  during  the  first  two  days.  It  may  be 
diffuse  or  circumscribed.  The  former,  according  to  Von  Graefe,  occui\s 
generally  in  from  twelve  to  twenty-four  hours  after  the  operation,  the 
latter  in  from  sixteen  to  thirty-six  hours.  The  lids  become  swollen  and 
red,  the  eye  painful,  and  there  is  a  more  or  less  copious  muco-purulent 
discharge.  On  opening  the  eye,  we  may  find  a  considerable  degree  of 
chemosis  surrounding  the  cornea.  Ii  the  suppuration  is  partial,  the 
edges  of  the  wound  will  show  a  yellow  purulent  infiltration,  which 
extends  deeply  into  the  substance  of  the  coi'nea,  the  whole  of  the  flap 
perhaps  also  becoming  opaque.  The  remainder  of  the  cornea,  how- 
ever, retains  its  transparency  sufficiently  to  jjermit  our  seeing  the  iris 
at  this  point.  But  if  the  suppuration  is  diffuse,  the  infiltration  is  not 
confined  to  the  line  of  incision,  but  extends  round  the  cornea,  the 
whole  expanse  of  which  assumes  an  opaque  yellow  tinge.  We  must 
consider  diffuse  suppuration  as  hopeless,  for  the  inflammation  generally 
extends  to  the  iris  and  ciliary  body,  and  in  the  worst  cases  general 
inflammation  of  the  eye  (panophthalmitis)  ensues.  If  this  occurs,  the 
inflammatory  sjTnptoms  become  greatly  intensified,  the  pain  is  often 
excruciating,  the  lids  greatly  swollen,  the  discharge  thick,  purulent, 
and  profuse.  We  can  then  only  endeavour  to  alleviate  the  sufferings  of 
the  patient  by  the  application  of  warm  sedative  poultices  or  fomenta- 
tions, for  all  hopes  of  saving  the  eye  are  gone.  But  the  partial  sup- 
puration of  the  cornea  must  also  be  regarded  with  great  anxiety,  for 
it  may  not  only  pass  over  into  the  diffuse  form,  but  it  may  give  rise  to 
suppurative  iritis  or  iridocyclitis,  which  may  end  in  atrophy  of  the 
globe.  It  has  been  long  a  keenly- debated  question  whether  the  sup- 
puration commences  in  the  iris  and  passes  thence  to  the  cornea,  or 
whether  it  originates  in  the  latter,  and  extends  secondarily  to  the  iris 
and  ciliary  body.  Von  Graefe  maintains  the  latter  view.  According 
to  him,  the  iritis  which  occurs  at  this  early  stage  is  propagated  or 
secondary,  whereas  that  which  comes  on  at  a  later  period  is  primary  or 
simple  iritis.  In  partial  suppuration  of  the  cornea  we  must  endeavour 
if  possible  to  prevent  its  extension,  and  this  can  only  be  done  by  sup- 
porting the  patient  by  nutritious  diet,  bark  and  ammonia,  and 
stimulants,  and  by  the  application  of  a  pressure  bandage.  No  other 
local  remedies  vnll  prove  of  any  avail.  Von  Graefe  first  pointed  out 
the  advantage  of  the  pressure  bandage  in  such  cases,  and  I  have  myself 
frequently  seen  it,  in  his  practice,  of  the  greatest  benefit  in  limiting 
the  suppuration  of  the  cornea,  and  can  therefore  strongly  recommend 
it.  In  very  feeble  decrepid  individuals  it  may  be  alternated  with  warm 
camomile   or  poppy  fomentations,  which   should  be  applied  for  an  hour 


246  DISEASES   OP   THE  CRYSTALLINE  LENS. 

at  intervals  of  two  to  three  hours.  I  know  that  many  surgeons  will 
view  the  application  of  a  pressure  bandage  to  an  eye  affected  with  sup- 
puration of  the  coi'nea  with  astonishment  and  incredulity ;  it  is, 
however,  certain  that  it  often  proves  very  beneficial,  and  tends  more 
than  any  other  remedy  to  diminish  the  swelling  of  the  lids  and  the 
discharge,  and  to  limit  the  suppuration  of  the  cornea.  So  much  care 
and  nicety  are  required  in  applying  the  pressure  bandage,  that  the 
surgeon  shoxJd  always  do  this  himself,  unless  he  has  an  exceptionally 
trustworthy  and  dexterous  nurse.  Von  Graefe  has  also  called  atten- 
tion to  the  very  important  fact,  that  in  very  old  and  feeble  individuals 
suppuration  of  the  cornea  may  occur  without  their  having  experienced 
the  slightest  pain  or  uneasiness  in  the  eye.  The  surgeon,  perhaps, 
congratulates  himself  upon  the  apparently  excellent  progress  of  the 
case,  and  then,  on  opening  the  eye,  finds  the  cornea  suppui'ated. 

The  primary  or  simple  iritis  which  may  occur  after  the  extraction 
does  not  generally  come  on  before  the  fourth  or  fifth  day  after  the 
operation.  It  may  be  due  to  the  bruising  or  contusion  of  the  iris  by 
the  instruments,  or  by  the  passage  of  the  lens  through  the  pupil,  or  it 
may  be  set  up  by  the  irritation  produced  by  portions  of  lens  substance 
which  have  remained  behind.  The  patient  experiences  pain  in  and 
around  the  eye ;  the  lids  become  swollen,  and  there  is  more  or  less 
photophobia  and  lachrymation.  On  opening  the  eye,  we  may  find  a 
considerable  amount  of  chemosis  surrounding  the  cornea,  which  is 
clear,  but  the  aqueous  humour  is  somewhat  clouded,  the  iris  discoloured, 
and  the  pupil  contracted.  If  the  patient  is  sufiicieutly  strong,  much 
benefit  is  derived  from  the  application  of  leeches  to  the  temples.  A 
strong  solution  of  atropine  (four  grains  to  the  ounce  of  water)  should 
be  frequently  applied,  so  that  the  pupil  may  be  widely  dilated.  Bella- 
donna ointment  should  be  rubbed  over  the  forehead  three  or  four  times 
daily. 

If,  after  flap  extraction,  the  case  has  throughout  progressed  favour- 
ably, the  patient  may  be  permitted  to  leave  his  bed  for  an  hour  or  two 
at  the  end  of  the  fifth  or  sixth  day.  He  should,  however,  wear  a  light 
bandage,  and  the  room  be  somewhat  darkened,  but  it  should  at  the  same 
time  be  kept  cool  and  well  ventilated.  If  the  remaining  in  bed  proves 
very  irksome,  which  is  apt  to  be  the  case  in  country  people  accustomed  to 
an  active  life,  it  may  be  well  to  permit  the  patient  to  get  up  even  on  the 
third  or  fourth  day.  But  then  he  must  be  very  carefully  watched.  In  a 
hospital  in  which  there  are  no  special  eye  wards,  the  bed  should  have  dark 
blue  curtains  round  its  head,  so  as  to  afford  a  protection  against  cold 
and  draught,  and  the  bright  light  of  the  ward.  In  such  a  case  I  think 
it  also  very  advisable  to  keep  the  patient  in  bed  some  days  longer  than 
would  be  necessary  in  a  private  room  or  a  special  ward.  At  the  end 
of  the  first  week,  the  bandage  may  generally  be  exchanged  for  a  shade, 


I 


FLAP  EXTRACTION.  247 

and  tlic  patient  be  gradually  accnstomed  to  the  light.  Should,  how- 
ever, any  inflammatory  symptoms  appear,  such  as  photophobia,  lachry- 
mation,  swelling  of  the  lids,  etc.,  the  bandage  should  be  re-applied,  and 
increased  care  be  taken  of  the  eye.  If  the  weather  is  favourable,  the 
patient  may  go  out  into  the  aii*  at  the  end  of  a  fortnight.  This  often 
proves  of  great  benefit,  especially  if  there  is  any  conjunctivitis,  which 
is  apt  to  become  chronic  if  the  confinement  to  the  house  has  been  long. 
In  such  a  case  a  weak  astringent  collyrium  should  be  prescribed. 

I  have  already  mentioned  that  in  certain  cases  of  immature  senile 
cataract,  in  which  the  progress  is  extremely  slow,  and  the  opacity  sot 
advanced  or  situated  (e.g.,  at  the  posterior  pole  of  the  lens)  as  to  impair 
vision  considerably,  it  may  be  advisable  to  hasten  the  progress  of  the 
cataract  by  pricking  the  capsule  and  admitting  the  aqueous  humour  to 
the  lens  substance.  Great  care  must,  however,  be  taken  not  to  divide 
the  capsule  too  freely,  as  this  may  cause  considerable  swelling  of  the 
lens  substance  and  give  rise  to  severe  iritis  or  iridocyclitis.  It  is  much 
better  to  make  only  a  small  opening  in  the  capsule,  and  to  repeat  the 
operation,  if  necessary,  several  times,  more  especially  if  a  considerable 
portion  of  'the  lens  is  still  transparent.  If  severe  inflammation  super- 
venes, and  if  it  does  not  yield  rapidly  to  antiphlogistics,  it  is  advisable, 
moi*e  especially  if  the  tension  of  the  eye  is  increased,  to  remove  the  lens 
at  once,  either  by  the  flap  extraction  or  Von  Graefe's  operation  ;  in  the 
former  case  it  would  be  well  to  make  at  the  same  time  a  large  ii'idec- 
tomy. 

Von  Graefe*  has  recommended  that  a  downward  ii'idectomy  should 
precede  the  laceration  of  the  capsule.  About  five  or  six  weeks  after- 
wards he  makes  a  superficial  crucial  incision  in  the  capsule  with  a  fine 
needle  (the  pupil  having  been  previously  widely  dilated  by  atropine). 
The  vertical  incision  should  extend  to  within  about  half  a  line  of  the 
edge  of  the  dilated  pupil,  whereas  the  horizontal  one  is  to  be  shorter, 
corresponding  only  to  the  transverse  diameter  of  the  normal  pupil.  The 
needle  must  not  penetrate  deeply  into  the  lens  substance,  otherwise  the 
lens  may  be  displaced.  The  pupil  is  to  be  kept  widely  dilated  by  atro- 
pine, in  order  to  afibrd  plenty  of  room  for  the  swelling  of  the  lens,  and 
prevent  its  pressing  upon  the  iris  and  ciliary  body.  Generally,  but  very 
slight  irritation  follows  the  laceration  of  the  capsule,  and  flap  extraction 
may  be  performed  from  about  six  to  twelve  days  afterwards,  when  the 
cataract  will  readily  escape.  For  reasons  already  stated,  I  prefer  making 
the  iridectomy  upwards. 

I  have  before  stated  that  the  chief  dangers  to  be  feared  after  flap 
extraction  are  suppuration  of  the  cornea,  prolapse  of  the  iris,  and  iritis. 

*  "  Arcliiv.  f.  Ophtlialmologie,"  x,  2, 20^  vicle  also  a  paper  upon  this  subject  by 
Dr.  Mannhardt  in  the  "  Sitzungsbericht  dcr  Oplithahnologischen  Gesellschaft," 
1864. 


248  DISEASES  OF   THE   CRYSTALLINE  LENS. 

The  principal  causes  wliicli  may  produce  the  latter  are — 1.  Bruising  of 
the  iris  by  the  instruments  and  by  the  passage  of  the  cataract  through 
the  pupil,  more  especially  if  the  latter  is  small  and  somewhat  rigid,  so 
that  it  dilates  with  difficulty.  2.  The  contusion  and  irritation  which 
the  iris  may  suffer  in  the  attempts  to  replace  a  prolapse.  3.  The  irri- 
tation set  up  by  portions  of  lens  matter  remaining  behind  the  iris  or 
adhering  to  the  pupil,  which  is  especially  apt  to  occur  if  the  pupil  is 
small  and  rigid,  and  the  cataract  immature,  or  if  it  possesses  a  small 
nucleus,  with  a  considerable  portion  of  softish  cortical  substance.  Now, 
in  accordance  with  the  fact  that  the  segment  of  the  iris  corresponding 
to  the  corneal  section  is  the  portion  most  exposed  to  these  different  in- 
fluences, we  find  that  it  almost  always  forms  the  starting-point  of  the 
inflammation  (iritis).  In  order  to  diminish  these  dangers  it  has  been 
proposed  to  remove  this  portion  of  the  iris  prior  to  the  extraction  of 
the  cataract — to  perform,  in  fact,  a  preliminary  iridectomy.  Von  Grraefe 
originally  pointed  out  that  such  a  proceeding  might  be  advantageous  in 
some  cases,  and  Dr.  Mooren  has  more  lately  submitted  this  plan  to  an 
extensive  trial,  with  marked  success.  There  can  be  no  doubt  that  it 
renders  flap  extraction  a  much  more  safe  operation ;  for  as  a  segment  of 
the  ii'is  corresponding  to  the  apex  of  the  flap  is  removed,  there  is  far 
less  danger  of  wounding  the  iris  with  the  instruments  or  of  its  being 
contused  by  the  passage  of  the  lens,  for  the  wide  artificial  pupil  permits 
the  ready  exit  of  the  cataract,  so  that  there  is  also  much  less  fear  of  por- 
tions of  cortical  substance  remaining  behind.  Even  if  the  latter  should 
occur,  there  is  more  room  for  these  fragments  to  swell  up,  and  they  will 
therefore  exert  a  far  less  deleterious  influence  upon  the  iris  and  ciliary 
body.  The  danger  of  prolapse  of  the  iris  is  also  diminished,  and  it  can 
only  occur  at  the  angles  of  the  incision.  According  to  Von  Graefe,  a 
preliminary  iridectomy  does  not,  however,  guard  against  either  difiuse 
or  partial  suppuration  of  the  cornea,  but  he  thinks  that  it  certainly 
exerts  a  favourable  influence  upon  the  course  of  the  latter,  and  on  the 
secondary  iritis,  as  it  diminishes  their  intensity.  The  iridectomy 
should  be  made  upwards,  as  it  will  then  be  covered  by  the  upper  lid ; 
the  subsequent  flap  operation  is  of  course  to  be  made  in  the  same  direc- 
tion. Mooren  makes  it  about  a  fortnight  before  the  extraction,  but  it 
is  better  to  permit  .a  longer  period  (from  four  to  six  weeks)  to  elapse 
between  the  performance  of  the  two  operations,  so  that  all  irritation 
may  have  subsided,  and  the  edges  of  the  artificial  pupil  have  become 
cicatrised. 

Let  us  now  consider  in  what  cases  it  may  be  advisable  to  perform 
this  modified  flap  extraction.  Mooren  recommends  it  in  all  cases  where 
the  patient  is  very  old  and  decrepid,  where  the  pupil  does  not  dilate 
quickly  and  fully  under  atropine,  where  the  nucleus  of  the  cataract  is 
small  and  surrounded  by  hardish,  coherent  cortical  substance,  portions 


FLAP  EXTRACTION,  249 

of  AA'liicli  may  easily  be  rubbed  off  during  the  exit  of  the  lens,  remain 
behind,  and  give  rise  to  severe  iritis,  or  even  irido- choroiditis.  Again, 
in  diabetic  cataract  there  is  not  only  the  fear  of  suppuration  of  the 
cornea  if  the  patient  is  very  feeble,  but  there  is,  moreover,  a  special 
tendency  to  iritis,  as  the  iris  is  extremely  impatient  of  contusion  and 
irritation.  But  then  we  must  also  remember  the  danger  of  submitting 
such  a  patient,  who  is  perhaps  already  in  a  very  weak  state  of  health, 
to  the  anxiety  and  shock  of  two  difierent  operations.  In  fact,  we  find 
that  even  persons  in  good  health  are  frequently  most  unwilling  to 
undergo  two  operations.  To  avoid  this  inconvenience,  the  iridectomy 
may  be  combined  with  the  operation  of  extraction,  as  has  been  advised 
by  Professor  Jacobson,  who  has  introduced  the  following  modification 
of  the  ordinary  flap  extraction.  The  patient  having  been  placed  fully 
under  the  influence  of  chloroform,  the  downward  section  is  made,  the 
puncture  and  counter-puncture  lying  half  a  line  below  the  horizontal 
meridian  of  the  cornea,  and  not  in  the  substance  of  the  latter,  but  in  the 
sclero-corneal  junction,  as  he  thinks  that  union  is  more  readily  effected 
here  than  in  the  cornea  itself.  After  the  lens  has  been  removed  in  the 
usual  manner,  the  corresponding  segment  of  the  iris  is  to  be  excised,  for 
by  this  proceeding  the  risk  of  iritis,  prolapse  of  the  iris,  and  suppura- 
tion of  the  cornea  is  diminished.  Professor  Jacobson  states,  in  his 
treatise  upon  this  operation,  published  in  1863,  that  he  had  up  to  that 
time  operated  upon  100  cases  by  this  method,  and  had  only  lost  two 
eyes.  It  is  to  be  regretted,  however,  that  he  has  not  furnished  more 
ample  details  of  the  100  cases,  more  especially  as  to  their  progress 
and  the  amount  of  vision  restored,  etc.,  so  that  a  more  accurate  opinion 
could  have  been  formed  of  the  real  success  of  his  operations.  My  chief 
objections  to  this  modification  are,  thr  direction  of  the  iridectomy,  and 
that  the  iris  is  to  be  excised  after  the  removal  of  the  lens.  The  down- 
ward iridectomy  is  not  only  unsightly,  but  it  causes  considerable 
dazzling  and  confusion  of  vision  on  account  of  the  circles  of  diffusion  on 
the  retina,  more  especially  when  cataract  glasses  are  used,  and  this 
proves  of  great  inconvenience  to  the  patient,  particularly  in  walking, 
crossing  a  street,  etc.  The  excision  of  the  iris  after  the  removal  of  the 
lens  is  not  only  difficult,  but  even  attended  by  some  risk  of  losing 
vitreous  humour  in  attempting  to  seize  and  draw  out  the  iris,  more 
especially  if  the  eye  has  to  be  fixed  with  a  pair  of  forceps.  Moreover, 
there  is  no  reason  why,  if  the  iridectomy  is  to  be  made  at  all,  it  should 
not  be  done  before  the  extraction  of  the  lens,  which  is  much  easier  and 
attended  by  far  less  risk. 

I  have  mentioned  that  Professor  Jacobson  places  the  patient 
thoroughly  under  the  influence  of  chloroform.  Most  operators  (amongst 
whom  I  must  include  myself)  have  hitherto  been  afraid  of  giving 
chloroform  in  flap  extraction,  on  account  of  the  danger  of  vomiting  or 


250  DISEASES  OF   THE   CRYSTALLINE   LENS. 

retching  during  or  after  tlie  operation.  The  wound  is  so  large  (em- 
bracing nearly  half  the  cornea)  that  a  fit  of  vomiting  or  severe  retching 
may  cause  a  great  loss  of  vitreous  humour,  and  may  even  force  out  the 
retina  and  choroid.  Professor  Jacobson  states,  however,  that  there  is 
no  danger  of  vomiting  if  the  patient  be  thoroughly  narcotised,  and 
Mr.  Windsor,  of  Manchester,  has  lately  published*  a  series  of  twenty  cases 
of  flap  extraction  successfully  performed  under  chloroform.  He  says  : — 
"  The  result  has  been,  I  think,  sufficiently  satisfactory ;  in  no  case  did 
the  chloroform  appear  to  have  any  injurious  influence.  Seventeen 
operations  were  unattended  by  any  accident ;  in  three  a  little  vitreous 
was  lost.  Vomiting  occurred  within  a  few  hours  in  four  cases,  but 
appeared  to  have  no  pernicious  efiect."  If  choroform  is  given  in  eye 
operations,  the  patient  should  be  placed  thoroughly  under  its  in- 
fluence ;  otherwise  it  is  better  to  abstain  altogether  from  its  use. 
These  operations,  more  especially  those  upon  the  iris  and  for  cataract, 
are  of  so  dehcate  a  nature,  that  a  sudden  start  of  the  patient's  head,  or 
a  fit  of  vomiting  or  retching,  may  not  only  endanger  the  result  of  the 
operation,  but  even  the  safety  of  the  eye.  Wlien  the  patient  is  so  deeply 
narcotized,  the  sudden  inhalation  of  a  strong  dose  of  chloroform  may 
prove  very  dangerous ;  and  it  is  therefore  of  great  importance  to  know 
exactly  what  percentage  of  chloroform  the  patient  is  breathing.  For 
this  reason  I  greatly  prefer  Clover's  apparatus  for  administering  chloro- 
form. It  is  not  only  the  safest  method,  but  by  no  other  have  I  uni- 
formly seen  such  j)erfect  tranquillity  and  unconsciousness  produced, 
without  there  being  any  cause  for  fear.  There  is  little  or  no  struggling 
or  straining  ;  the  patient  breathes  calmly  and  quietly  ;  and  when  he  is 
thoroughly  under  its  influence  the  most  difficult  and  delicate  ophthalmic 
operations  may  be  performed  without  fear  or  risk.  In  order  that  there 
may  be  no  vomiting  or  retching,  strict  orders  should  be  given  that  the 
patient  does  not  take  any  food  or  drink  for  three  or  four  hours  prior  to 
the  operation. 

5.— REMOVAL  OF  THE  LENS  IN  ITS  CAPSULE. 

This  operation  has  been  especially  recommended  for  the  following 
cases: — 1.  Capsular  cataract.  2.  Cataract  complicated  with  choroiditis, 
or  irido- choroiditis ;  for  in  such  cases  the  eye  is  extreraely  irritable, 
and  if  portions  of  lens  matter  are  left  behind  they  are  apt  to  set  up 
very  destructive  inflammation ;  moreover,  the  connexion  between  the 
posterior  capsule  and  the  hyaloid  is  apt  to  be  loosened.  3.  Retro- 
gressive cataract,  in  which  the  lens  is  somewhat  shrivelled.  If  some 
of  its  constituents  have  undergone  fatty  or  chalky  degeneration,  con- 
siderable portions  of  lens  matter  are  liable  to  adhere  to  the  capsule  and 

*  "  Ophthalmic  Eeview,"  vol.  ii,  365. 


EXTRACTION  OF  THE  LENS  IN  ITS  CAPSULE.       251 

remain  behind  wlien  the  cataract  is  removed,  setting  np  more  or  less 
severe  inflammation  and  giving  rise  to  dense  secondary  cataract.  4. 
Immature  cataract,  in  which  there  is  also  danger  of  lens  substance 
remaining  behind. 

This  operation  was  originally  practised  by  Richter  and  Beer,  but 
fell  into  disuse  until  it  was  lately  re-introduced  by  Sperino,  Pagon- 
stecher,  and  Wecker.  Pagenstecher  performs  it  in  the  following 
manner : — The  patient  having  been  placed  thoroughly  tinder  chloro- 
form, he  makes  a  flap  incision  (generally  downwards)  lying  throughout 
its  whole  extent  in  the  sclerotic,  and  not  in  the  cornea ;  at  the  apex  of 
the  flap  he  leaves  a  small  bridge  of  conjunctiva  standing.  He  next 
makes  a  large  iridectomy  downwards  and  outwards,  and  then  divides 
the  conjunctival  bridge  with  a  pair  of  blunt-pointed  scissors.  If  any 
posterior  synechia3  exist,  he  divides  them  with  a  fine  silver  hook  passed 
between  the  edge  of  the  pupil  and  anterior  capsule  ;  then,  by  slight 
pressure  upon  the  eye,  he  endeavours  to  remove  the  lens  in  its  capsule ; 
but  if  the  hyaloid  membrane  should  be  ruptured,  and  vitreous  escape, 
he  passes  in  a  small  scoop  behind  the  lower  edge-  of  the  lens  and  to  its 
posterior  surface,  and  thus  removes  it  with  the  capsule.  Up  to  the 
year  1864  he  had  operated  in  this  way  upon  fifty- four  cases  of  cataract 
of  various  kinds  with  marked  success.  Only  two  eyes  were  lost 
through  suppuration,  and  in  a  third  case  there  was  some  iritis  dependent 
upon  previous  opacity  of  the  vitreous,  but  the  result  of  this  operation 
was  fairly  good,  the  patient  being  able  to  read  ISTo.  16  with  convex  3. 
In  not  one  of  the  remaining  fifty-one  cases  was  there  the  slightest 
iritis.  In  some  of  these  cases  the  lens  was  extracted  without  the  aid  of 
the  scoop,  and  without  loss  of  vitreous,  the  same  occurring  sometimes 
even  when  the  scoop  was  employed ;  in  others  more  or  less  vitreous 
was  lost. 

Wecker  operates  in  a  very  similar  manner,  except  that  he  does  not 
make  his  incision  so  much  in  the  sclerotic  as  Pagenstecher,  and  does 
not  leave  a  conjunctival  bridge.  A  portion  of  iris  having  been  excised, 
he  passes  a  curette  behind  the  lens  and  draws  it  out  in  its  capsule. 
When  the  lens  has  reached  the  incision,  an  assistant,  grasping  its  edge 
with  a  Daviel's  cui-ette,  extracts  it.  His  results  have  also  been  very 
favourable,  and  he  has  often  succeeded  in  extracting  the  lens  without 
any  loss  of  vitreous.  The  latter  accident  is  almost  sure  to  occur  if 
chloroform  is  not  given,  or  if  the  patient  is  not  thoroughly  under  its 
influence.  When  a  mature  senile  cataract  has  existed  for  many  years, 
it  often  adheres  somewhat  closely  to  the  capsule,  and  the  relations  of 
the  latter  with  the  suspensory  ligament  are,  moreover,  generally  some- 
what relaxed,  so  that  the  lens  can  be  unusually  easily  removed  in  its 
capsule.  This  fact  has  been  especially  pointed  out  by  Mr.  Bowman, 
who  has  succeeded  in  several  cases  in  extracting  the  lens  in  its  capsule 


252  DISEASES   OF   THE   CRYSTALLINE  LENS. 

by  Graefe's  operation.  If,  on  attempting  this,  it  is,  however,  found 
that  the  lens  does  not  come  readily,  it  is  much  better  to  divide  the 
capsule  freely,  than  to  force  the  exit  of  the  lens  in  the  capsule  at  the 
expense  of  a  great  loss  of  vitreous,  and  perhaps  the  dislocation  of  the 
lens  into  the  vitreous  humour. 

6.— LINEAR  EXTRACTION. 

Before  I  describe  this  mode  of  operating,  let  us  glance  for  a  moment 
at  its  history.*  In  1811,  Gribson  introduced  it  as  supplementary  to 
the  needle  operation,  in  those  cases  of  soft  cataract  in  which  the  lens 
(after  having  been  divided)  was  not  absorbed  with  the  desired  rapidity 
or  success.  He  also  employed  it  in  capsular  and  membranaceous 
cataract.  His  mode  of  operating  consisted  in  removing  the  lens 
through  a  small  corneal  section,  which  was  about  three  lines  in  extent, 
and  was  situated  about  one  line  from  the  sclerotic.  In  1814,  Travers, 
after  dividing  the  capsule,  displaced  the  lens  into  the  anterior  chamber, 
and  then  removed  it  through  a  small  corneal  section.  He,  however, 
subsequently  gave  up  this  method,  and,  making  a  quarter  section  of 
the  cornea,  divided  the  capsule  with  the  point  of  the  knife,  and,  if  the 
lens  was  sufficiently  soft,  he  let  it  escape  through  the  section,  but  if  it 
was  too  firm  for  this,  he  introduced  a  curette  into  the  anterior  chamber, 
and  by  its  aid  removed  the  lens  piecemeal.  Both  the  operations  of 
Gibson  and  Travers  fell  into  disuse,  until  about  1851,  when  Bowman 
and  Graefe,  quite  independently  of  each  other,  re-introduced  linear 
extraction.  Von  Graefe,  having  worked  out  the  subject  extensively 
and  with  great  care,  states  in  his  first  essay  upon  itf  that  the  linear 
extraction  is  especially  indicated  in  the  cortical  cataract  of  youthful 
individuals,  and  also  in  those  cases  in  which  there  is  so  much  swelling  up 
of  the  lens  substance  (either  in  consequence  of  a  needle  operation,  or  of 
some  injury  to  the  lens)  as  to  threaten  the  safety  of  the  eye.  But  he 
thinks  it  unsuitable  if  the  lens  retains  its  normal  consistence,  and 
still  more  so,  if  there  is  a  hardish  nucleus.  As  a  general  rule,  linear 
extraction  is,  therefore,  indicated  in  cases  of  cortical  cataract,  occurring 
between  the  age  of  ten  and  thirty,  or  even  thii'ty-five.  It  is  also  often 
employed  with  advantage  as  supplementary  to  the  needle  operation. 
Linear  extraction  is  to  be  performed  in  the  following  manner.  The 
pupil  having  been  previously  well  dilated  with  atropine,  and  the  patient 
placed  under  the  influence  of  chloroform,  the  eyelids  are  to  be  kept 
apart  by  Weiss' s  spring  speculum,  and  the  eye  steadied  with  a  pair  of 

*  For  an  interesting  historical  sketch  of  this  operation,  I  must  refer  the 
reader  to  Von  Graefe's  paper  on  "  Modified  Linear  Extraction,"  "  Arch.  f.  Oph- 
thalm.,"  xi,  3. 

t  "  Arch.  f.  Ophthalin.,"  i,  2. 


LINEAR   EXTRACTION.  253 

forceps.  An  incision  is  then  to  be  made  in  the  cornea,  at  its  temporal 
side,  and  about  one  line  from  the  sclerotic,  with  a  broad  sti'aight  iridec- 
tomy knife.  The  incision  should  be  about  from  two  to  two  and  a  half 
lines  in  extent.  The  capsule  is  then  to  be  divided  with  the  cystotome, 
and  the  lens  removed.  In  order  to  facilitate  the  exit  of  the  cataract, 
the  convexity  of  the  curette  is  to  be  placed  against  the  edge  of  the 
cornea,  which  causes  the  section  to  gape ;  a  slight  counter-pressure, 
being  at  the  same  time  exerted  by  the  forefinger  of  the  left  hand, 
which  is  to  be  lightly  placed  against  the  inner  side  of  the  eyeball.  By 
alternately  pressing  with  the  curette  and  the  finger,  the  soft  lens  sub- 
stance will  readily  exude  through  the  incision.  If  portions  of  cor- 
tical substance  remain  behind  the  iris,  the  lids  are  to  be  closed, 
and  the  globe  lightly  rubbed  in  a  circular  direction  to  bring  these 
flakes  into  the  pupil  or  anterior  chamber,  whence  they  may  be  readily 
removed.  Or  Mr.  Bowman's  suction-syringe  may  be  employed  for  this 
purpose.  Should  the  iris  protrude  through  the  incision,  it  must  be 
gently  replaced,  but  if  it  has  been  much  bruised  by  the  exit  of  the  lens 
or  the  movements  of  the  curette,  it  will  be  wiser  to  excise  a  portion  of 
it.  A  light  compress  bandage  is  to  be  applied  after  the  operation,  and 
the  pupil  should  be  kept  well  dilated  with  atropine. 

Von  Graefe  found  that,  although  occasionally  a  cataract  possessing 
a  firm  nucleus  may  be  removed  through  a  linear  incision  without  danger, 
yet  that,  as  a  rule,  this  operation  is  inapplicable  when  the  nucleus  is 
hard,  for  the  iris  must  then  be  more  or  less  bruised  by  the  passage  of 
the  lens  through  the  narrow  section.  The  scoop  may  also  have  to  be 
introduced  into  the  anterior  chamber  behind  the  lens,  so  as  to  facilitate 
its  removal,  and  this,  of  course,  adds  to  the  contusion  of  the  iris.  Great 
irritation  of  the  latter  is  likewise  often  produced  by  portions  of  hardish 
lens  substance  remaining  behind  the  iris  or  in  the  pupil.  Now,  as  the 
segment  of  the  iris  which  corresponds  to  the  incision  is  the  most 
exposed  to  bruising,  and  interferes  the  most  with  the  ready  use  of  the 
scoop,  we  find  that  this  is  almost  always  the  starting  point  of  any  sub- 
sequent iritis.  In  those  cases  in  which  there  was  a  somewhat  firm 
nucleus.  Von  Graefe  was  therefore  led  to  modify  the  linear  extraction, 
and  to  excise  a  portion  of  iris  prior  to  the  laceration  of  the  capsule, 
and  then  to  remove  the  lens  with  a  broad  flat  scoop.*  The  stages 
of  this  operation  were  as  follows: — I.  The  incision  was  made  at  the 
edge  of  the  cornea  (temporal  side),  and  embraced  about  a  quarter  of 
its  circumference.  2.  A  portion  of  iris  was  removed,  the  size  of  which 
did  not,  however,  quite  equal  the  extent  of  the  incision.  3.  The  cap- 
sule was  freely  divided  quite  up  to  the  margin  of  the  lens.  4.  A  scoop 
was  then  introduced  at  the  free  edge  of  the  lens  and  gently  inserted 
between  the  posterior  cortical  substance  and  the  nucleus,  and  the  cataract 
*  "  Arckiv.  f.  Ophthalm.,"  v,  1. 


254  DISEASES   OF   THE   CRYSTALLINE   LENS. 

lifted  into  the  anterior  chamber  and  extracted.  The  scoop  which  he 
employed  for  this  pui'pose  was  shallower,  broader,  and  sharper  at  the 
extremity  than  Daviel's  curette.  Thus  originated  the  modified  linear  or 
scoop  extraction — an  operation  which  afterwards  assumed  so  important 
a  position  in  ophthalmic  surgery.  By  this  modification,  Von  Graefe 
greatly  extended  the  applicability  of  the  linear  extraction,  for  he  was 
now  able  to  remove  through  a  linear  incision  cataracts  whose  cortex 
was  of  a  pulpy  consistence,  and  the  nucleus  moderately  large  and  hard, 
a  form  of  cataract  which  would  otherwise  have  necessitated  the  flap 
extraction.  I  would  here  remark  that  to  Von  Graefe  belongs  the  credit 
of  having  first  suggested,  in  some  cases,  the  combination  of  an  iiT.dec- 
tomy  with  flap  extraction,  and  also  of  having  introduced  the  modified 
linear  or  scoop  extraction.  The  principle  of  the  latter  operation  is 
essentially  his,  whatever  changes  may  be  made  in  the  shape  of  the  scoop, 
and  it  is  worthy  of  remark  that  the  latest  operations  assimilate  it  more 
to  that  originally  used  by  him.  Mr.  Critchett  has  already  pointed  out 
these  facts  in  his  admirable  paper  upon  scoop  extraction,*  in  which  he 
says: — "Thus  there  suddenly  appeared  three  new  methods  of  operating 
for  cataract,  bearing  the  name  of  their  several  champions — the  method 
of  Mooren,  Jacobson,  and  that  of  Schuft  (Waldau)  ;  but  justice  compels 
me  to  state  that  these  gentlemen  Hghted  their  tapers  at  the  torch  of 
their  great  master  Professor  Von  Graefe.  Each  of  these  methods  had 
been  previously  suggested  and  practised  by  him,  but  only  in  exceptional 
cases,  instead  of  as  a  general  rule." 

Waldau  shortly  afterwards  contrived  a  difierent  form  of  scoop,  of 
varying  size,  which  was  deeper,  broader,  and  flatter  at  the  bottom  than 
Von  Graefe's.  Its  edges  were,  moreover,  high  and  thin,  so  as  to  bite 
into  the  lens,  the  anterior  lip  being  the  highest,  and  thus  facilitating 
the  removal  of  the  cataract  by  pressing  after  it.  By  its  aid  he  pro- 
posed to  remove  even  the  hard  senile  cataract.  It  was  soon  found, 
however,  that  this  form  of  scoop  was  too  large  and  cumbersome,  and  its 
edges  too  high  and  sharp,  and  that  it  was  therefore  difficult  to  introduce 
it  readily  behind  the  lens,  more  especially  in  hard  senile  catai'act,  in 
which  it  may  very  easily  cause  displacement  of  the  lens  or  rupture  of  the 
hyaloid  membrane.  Mr.  Bowman  and  Mr.  Critchett  have  since  devised 
some  forms  of  scoop  which  are  far  better  and  in  all  cases  preferable  to 
Waldau's.  The  scoop  operation,  as  performed  at  Moorfields,  has  proved 
remarkably  successful  in  the  hands  of  some  of  our  English  ophthalmic 
surgeons,  more  especially  in  those  of  Messrs.  Bowman  and  Critchett, 
who  have  worked  out  the  subject  most  thoroughly,  and  have  done  the 
most  to  bring  this  operation  to  perfection.  As  my  description  of  it 
must  be  necessarily  brief,  I  would  refer  the  reader  to  their  admirable 

*  "  Kojal  Loudon  Oplilhahuic  Uoepital  E-cpoi'ls,"  iv,  4,  319. 


SCOOP  EXTRACTION.  255 

articles  upon  this  subject  in  the  "  Royal  London  Ophthalmic  Hospital 
Reports,"  vol.  iv.,  p.  4. 

7.— SCOOP  EXTRACTION". 

Prior  to  the  operation,  the  pupil  should  be  widely  dilated  with 
atropine,  and  the  cataract  examined  by  the  oblique  illumination,  so  that 
the  size  and  hardness  of  the  nucleus  and  the  consistence  of  the  cortical 
substance  may  be  ascertained.  For  the  size  of  the  incision  should  be 
apportioned  to  that  of  the  nucleus,  and  to  the  extent  and  consistence 
of  the  cortical  substance.  Nothing  is  more  likely  to  mar  the  success  of 
the  operation  than  if  the  incision  is  too  small,  for  then  the  iris  and  the 
lips  of  the  section  must  be  more  or  less  bruised  during-  the  exit  of  the 
lens,  considerable  portions  of  the  latter  are  sure  to  be  stripped  off,  and, 
if  they  cannot  be  entii'ely  removed,  may  set  up  subsequent  inflammation. 
If  the  nucleus  is  small  and  the  cortex  softish,  the  incision  should 
embrace  about  a  quarter  of  the  circumference  of  the  cornea ;  but  if  the 
nucleus  is  large  and  hard — as,  for  instance,  in  the  senile  amber  cataract 
— and  the  cortex  firm,  the  size  of  the  incision  must  be  increased,  and 
should  extend  to  about  one-third  of  the  cornea.  The  section  must  also 
be  large,  if  the  cataract  is  over-ripe,  and  if  little  fatty  or  chippy  frag- 
ments have  collected  on  the  surface  or  at  the  margin  of  the  lens ;  for 
these  are  very  apt  to  be  stripped  off  and  left  behind  if  the  exit  of  the 
lens  is  rendered  difficult  and  forced  from  the  section  being  too  small. 

The  patient  should  be  placed  thoroughly  under  the  influence  of 
chloroform,  so  that  he  may  be  quite  tranquil  and  passive,  for  any  sudden 
stai-t  may  endanger  the  safety  of  the  eye,  more  especially  during  the 
period  of  the  introduction  of  the  scoop.  It  is,  moreover,  important 
that  the  different  steps  of  the  operation  should  be  performed,  if  possible, 
without  any  interruption  by  the  recoveiy  of  the  patient  from  the  effects 
of  the  chloroform;  for  if  this  happens  after  the  excision  of  the  iris,  and 
there  is  any  considerable  bleeding  into  the  anterior  chamber,  it  may 
be  impossible  to  remove  the  blood  before  it  has  become  coagulated, 
owing  to  the  time  lost  in  again  getting  the  patient  thoroughly  nar- 
cotised, and  this  will  considerably  enhance  the  difficulties  of  the  other 
steps  of  the  operation.  The  operation  of  scoop  extraction  is  divided 
into  four  periods.  1.  The  incision.  2.  The  iridedomij.  3.  The  laceration 
of  the  capsule.    4.  The  removal  of  the  cataract  hy  the  scoop. 

The  incision  is  to  be  made  in  the  upward  direction  with  a  broad, 
lance-shaped  knife  in  the  sclero- corneal  junction,  and  should  be  about 
from  foul'  to  four  and  a  half  lines  in  extent.  A  corresponding  portion 
of  the  iris  is  to  be  removed.  The  capsule  is  then  to  be  freely  lacerated 
with  the  pricker.  The  latter  is  to  be  passed  into  the  anterior  chamber 
as  fai'  as  the  opposite  edge  of  the  pupil,  and  even  a  little  beneath  the 


256 


DISEASES   OF   THE  CRYSTALLINE   LENS. 


margin  of  the  latter,  especially  if  there  be  slight  adhesions  of  the  edge 
of  the  pupil  to  the  capsule,  which  will  thus  be  torn  through.  The  point 
being  then  turned  towards  the  lens,  the  pricker  is  to  be  drawn  gently 
along  on  each  side  and  in  the  centre,  so  that  the  capsule  may  be  freely 
lacerated  quite  up  to  the  margin  of  the  lens  corresponding  to  the  inci- 
sion. But  the  instrument  must  be  used  very  lightly  and  delicately, 
otherwise  the  lens  may  be  dislocated,  especially  if  the  cataract  is  hard. 
The  next  and  most  difficult  step  of  the  operation  is  the  removal  of  the 
lens  by  the  scoop.  Waldau's  is  too  large  and  cumbersome,  and  either 
Mr.  Critchett's  or  Mr.  Bowman's  form  of  scoop  should  be  used.  The 
former.  Fig.  34,  is  so  constructed  as  to  glide  readily  behind  the  posterior 
surface  of  the  cataract.  It  is  thin,  flat,  and  concave,  so  as  to  adapt 
itself  accurately  to  the  posterior  convex  surface  of  the  lens.  At  the 
end  there  is  a  small  receding  edge,  which  assists  in  fixing  and  holding 
the  cataract,  and  thus  facilitates  its  removal.  Mr.  Bowman  thinks, 
however,  that  this  wedge-like  end  occupies  too  much  space  behind  the 
nucleus.  He,  therefore,  prefers  another  form  (Fig.  35),  the  end  of 
which  is  not  recurved,  but  looks  from  it  at  a  very  obtuse  angle,  and  the 
extreme  edge  is  very  thin.  The  sides,  except  towards  the  end,  have  no 
edge  above  the  general  level.  In  those  cases  in  which  there  is  no  soft 
matter  to  permit  room  for  the  insertion  of  the  scoop  between  the  lens 
and  capsule,  he  uses  a  different  shape  (Fig.  36).     This  instrument  is 


Fig.  34. 


Fig.  35. 


Fig.  36. 


nearly  flat  from  side  to  side,  and  but  slightly  concave  from  end  to  end. 
The  end  has  a  very  thin,  though  not  sharp,  edge  only  slightly  incurved, 
and  the  concave  surface  at  the  end  is  roughened  by  transverse  lines. 
For  those  forms  of  cataract  in  which,  together  with  a  large  firm  nucleus, 
there  is  a  sufiicient  layer  of  soft  cortical  substance  to  permit  the  easy 
passage  of  the  scoop,  I  generally  use  Mr.  Critchett's  instrument. 
When  this  is  not  the  case,  I  prefer  Mr.  Bowman's  second  form  (Fig. 
36). 

Great  dexterity,  delicacy,  and  care  are  required  in  the  use  of  the 
scoop,  which  is  to  be  lightly  held  between  the  forefinger  and  thumb. 
The  eye  having  been  fixed  with  the  forceps,  the  scoop  is  to  be  intro- 
duced into  the  section,  being  turned  directly  towards  the  back  of  the 
eye,  so  that  its  anterior  lip  may  glide  past  the  free  margin  of  the  lens 


SCOOP  EXTRACTION.  257 

exposed  by  the  iridectomy.  Ifc  is  of  great  consequence  to  remember 
that  tlie  scoop  is  to  be  at  first  directed  backwards,  for  if  it  be  passed 
forwards  and  downAvards  before  its  anterior  lip  has  skirted  the  edge  of 
the  lens,  the  nucleus  Avill  be  pushed  before  it,  and  even  perhaps  dis- 
placed behind  the  lower  portion  of  the  iris,  the  hyaloid  membrane  will 
in  all  probability  be  ruptured,  and  a  considerable  portion  of  the  vitreous 
humour  escape  even  before  the  body  of  the  lens  has  been  extracted. 
When  the  edge  of  the  scoop  has  passed  the  margin  of  the  lens,  it  is  to 
be  turned  quite  flat,  and  slowly  and  gently  insinuated  into  the  posterior 
cortical  substance  between  the  capsule  and  the  nucleus  until  its  further 
end  has  passed  the  margin  of  the  latter.  This  forward  movement 
must  be  veiy  delicately  performed  by  a  slightly  undulating  or 
"  wi'iggling  "  motion ;  for  if  the  scoop  is  roughly  pushed  on  it  may 
carry  the  lens  before  it,  and  thus  displace  it,  or  the  hyaloid  membrane 
may  be  ruptured  and  the  vitreous  humour  escape.  When  the  lens  is 
well  grasped  by  the  scoop,  it  should  be  slowly  removed,  care  being 
taken  that  its  anterior  surface  is  not  pressed  too  much  forward ;  other- 
Avise  it  will  bruise  the  iris  and  cornea,  a  not  unfrequent  cauvse  of  subse- 
quent iritis  and  circumscribed  corneitis.  If  small  portions  of  cortex 
have  been  stripped  off  during  the  passage  of  the  lens  into  the  anterior 
chamber,  and  lie  in  the  latter,  a  slight  backward  movement  of  the 
scoop  may  be  made  before  the  cataract  is  removed  through  the  incision, 
as  this  will  gather  up  such  fragments  and  draw  them  readily  after  the 
main  portion ;  or  they  may  be  afterwards  removed  with  a  smaller  scoop, 
slight  pressure  being  at  the  same  time  made  upon  the  globe  opposite 
the  incision.  If  the  detached  fragments  are  considerable,  and  cling  to 
the  edge  of  the  pupil,  or  remain  behind  the  iris,  the  speculum  should 
be  removed  and  the  eyelids  rubbed  in  a  circular  direction,  so  as  to 
bring  them  into  the  anterior  chamber,  whence  they  may  be  readily 
extracted  by  the  curette.  This  is  much  to  be  preferred  to  the  frequent 
introduction  of  the  scoop.  The  suction  syringe  may  also  be  employed 
for  the  removal  of  small  soft  fragments.  Any  little  portions  of  lens 
matter  that  may  cling  to  the  lips  of  the  incision  are  to  be  removed 
with  the  curette,  as  they  interfere  with  the  union  of  the  section,  and 
are  apt  to  give  rise  to  suppurative  infiltration  of  the  edge  of  the 
incision.  Should  a  little  of  the  vitreoiTS  humour  exude  through  the 
section  with  the  last  portion  of  lens,  it  must  be  snipped  off  and  a  com- 
press applied.  If  the  vitreous  escapes  directly  after  the  division  of 
the  capsule,  the  scoop  must  be  passed  well  behind  the  cataract  so  as  to 
extract  it,  if  possible,  en  masse.  If  the  loss  of  vitreous  does  not  occur 
until  the  body  of  the  lens  has  been  extracted,  any  fragments  of  lens 
that  remain  behind  should  be  removed.  If  they  can  be  easily  reached, 
the  curette  should  be  employed ;  otherwise  it  is  better  gently  to  rulj 
the  lids  and  bring  them  into  the  anterior  chamber,  whence  they  may  be 


258  DISEASES   OF   THE   CRYSTALLINE   LENS. 

readily  extracted.  More  or  less  vitreous  \\ill,  of  course,  be  lost,  but 
this  is  better  tlian  leaving  considerable  fragments  behind,  as  they 
swell  up  and  give  rise  to  great  irritation  and  inflammation  of  the  iris 
or  ciliary  body. 

The  after  treatment  is  for  more  simple  than  that  of  flap  extraction, 
and  it  is  very  similar  to  that  which  I  shall  describe  in  Von  Graefe's 
operation. 

8._V0N  GRAEFE'S  MODIFIED  LINEAR  EXTRACTION. 

Von  Graefe*  has  lately  devised  an  important  modification  of  the 
linear  extraction,  which  combines  the  advantages  of  the  flap  and  scoop 
extraction.  For  whilst  the  section  involves  but  a  small  portion  of  the 
cornea,  it  yet,  on  account  of  its  shape  and  mode  of  formation,  gapes 
sufficiently  to  permit  the  ready  exit  of  even  a  hard  senile  cataract 
without  the  aid  of  a  traction  instruruent.  The  operation  is  divided 
into  four  periods  : — 1.  The  incision ;  2.  The  iridectomy ;  3.  The  lacera- 
tion of  the  capsule ;  4.  The  removal  of  the  lens.  The  operation  is  to  be 
performed  in  the  following  manner : — 

1.  The  Incision. — The  patient  having  been  placed  under  the  influence 
of  chloroform,  the  eyelids  are  to  be  kept  apart  with  the  stop  speculum, 
and  the  eye  fixed  with  a  pair  of  forceps.  For  this  operation  I  greatly 
prefer  Mr.  Noyes's  (New  York)  speculum,  the  rack  and  screw  of  which 
are  on  the  nasal  side,  so  that  the  temporal  portion  of  the  eye  is  left 
quite  free  for  the  manipulation  of  the  knife  in  forming  the  section. 
Another  great  advantage  is  that  it  does  not  press  upon  the  eyeball, 
bu.t  lifts  the  lids  away  from  it.  The  speculum  may  be  obtained  of 
Messrs.  Krohne  and  Co.,  Whitechapel.  The  point  of  a  long  narrow 
knife  (Fig.  37),  with  its  cutting  edge  turned  upwards,  is  to  be  entered 

Fig.  37.  Fig.  38. 


in  the  sclerotic  (at  the  point  A,  Fig.  38)  near  the  upper  and  outer 
portion  of  the  cornea,  about  one-third  of  a  line  from  its  edge,  so  that  it 
may  enter  qiiitc  at  the  periphery  of  the  anterior  chamber.  The  point 
of  the  knife  shoaldbe  at  first  directed  downwards  and  inwards  towards 
c,  so  as  to  enlarge  the  inner  incision,  and  then,  when  the  blade  has 
advanced  about  three  and  a  half  lines  into  the  anterior  chamber,  the 
handle  is  to  be  depressed  and  the  point  carried  along  to  £,  where  the 

*  Vide  A.  f.  O.,  xi,  3,  xii,  1,  xiii,  1  aud  2,  xiv,  1. 


VON  graefe's  extraction.         259 

counter-puncttire  is  to  be  made.  Great  care  must  be  taken  that  the 
counter-puncture  does  not  fall  too  far  in  the  sclerotic,  which  might 
easily  occtu-  if  the  presentation  of  the  point  of  the  knife  is  not  care- 
fully watched,  or  the  blade  is  passed  too  fir  downwards  and  inwards, 
before  it  is  turned  upwards  to  make  the  counter-puncture.  Such  an 
accident  wilf  give  rise  to  a  Avide  gaping  wound,  and,  in  all  probability, 
to  great  loss  of  vitreous,  even  perhaps  before  the  iris  has  been 
excised,  and  certainly  during  the  pressure  which  has  to  be  made  upon 
the  globe  to  facilitate  the  exit  of  the  lens. 

As  soon  as  the  counter-puncture  has  been  made,  the  edge  of  the 
blade  is  to  be  turned  steeply  forwards,  and  the  knife  pushed  straight 
on  until  its  length  is  nearly  exhausted,  when  the  section  is  to  be 
finished  by  drawing  it  backwards  from  heel  to  point.  If  a  little 
bridge  should  remain,  it  is  to  be  divided  by  a  slight  sawing  m.ovement 
of  the  knife,  which  will  then  lie  under  the  conjunctiva,  which  is  next 
to  be  divided  in  such  a  manner  as  to  leave  a  conjunctival  flap  of  about 
one  line  to  a  lino  and  a  half  in  height.  In  order  that  it  may  not  exceed 
this  extent,  the  edge  of  the  blade  must  be  turned  horizontally  forwards, 
or  even  downwards.  If  the  cataract  is  hard  and  firm,  it  may  be 
advisable  to  use  a  somewhat  broader  knife,  and  to  make  the  points  of 
puncture  and  counter-puncture  one-third  of  a  line  lower. 

By  this  incision  the  track  of  the  wound  lies  almost  perpendicular 
to  the  sui'face  of  the  cornea,  and  is  steeper  (less  sloping)  than  that 
made  by  the  lance-shaped  knife.  Thus  the  exit  of  the  lens  is  greatly 
facilitated,  for  its  equator  passes  far  more  readily  into  the  track  of  the 
wound,  and  the  cortical  substance  exudes  also  more  easily.  There  is, 
however,  the  disadvantage  that  on  account  of  the  steepness  of  the 
section  the  suspensory  ligament  loses  its  support,  and  hence  there  is  a 
greater  tendency  to  loss  of  vitreous  than  if  the  incision  is  made  with 
the  lance-shaped  knife. 

In  senile  cataract  with  a  large,  firm  nucleus,  care  must  always  be 
taken  that  the  incision  is  sufficiently  large  to  permit  of  the  ready  exit 
of  the  lens  without  there  being  the  necessity  to  use  much  pressure 
upon  the  eye,  or  to  pass  in  a  scoop  to  remove  it.  In  such  cases  I 
always  make  the  puncture  and  counter-puncture  somewhat  lower  down 
and  nearer  the  horizontal  diameter  of  the  cornea,  which  is,  I  think,  to  be 
preferred  to  a  more  peripheral  position  of  the  section.  The  incision  lies 
throughout  slightly  in  the  sclerotic  (just  at  the  sclero-corneal  junction), 
for  I  believe  that  union  takes  place  much  more  rapidly  here  than  when 
the  section  lies  in  the  cornea.  Moreover,  the  section  is  sufficiently 
large  to  admit  of  the  easy  exit  of  the  cataract,  a  very  gentle  pressure 
with  a  curette  upon  the  lower  portion  of  the  cornea  sufficing  to  "  coax" 
it  out.  Mr.  Critchett,  on  the  other  hand,  prefers  to  make  the  section 
tkroughout  in  the  coi-nea  quite  close  to  its  edge,  as  he  thinks  that  there 

s  2 


2  GO  DISEASES  OF   THE   CRYSTALLINE  LENS. 

is  thus  less  chance  of  loss  of  vitreous  and  of  prolapse  of  the  iris.     He 
also  only  removes  a  very  small  portion  of  the  iris. 

2.  The  Iridectomy. — K  the  section  does  not  come  well  into  view,  an 
assistant  is  to  draw  the  eye  down  with  a  pair  of  forceps,  and  the  little 
conjunctival  flap  is  to  be  turned  back  over  the  cornea  with  a  pair  of 
very  small  iris  forceps.  The  prolapsed  portion  of  the  iris  will  thus  be 
laid  bare,  and  the  iris  should  be  drawn  forth  a  little  more  and  be 
excised  to  the  requii'ed  extent  quite  up  to  its  ciliary  insertion.  The  size 
of  the  iridectomy  must  vaiy  according  to  the  size  and  hardness  of  the 
nucleus,  and  also  according  to  the  position  of  the  upper  lid.  If  the 
nucleus  is  large  and  hard  I  think  it  Aviser  to  remove  a  considerable  por- 
tion of  the  iris,  even  perhaps  nearly  corresponding  to  the  whole  length 
of  the  incision.  This  will  permit  of  the  ready  exit  of  the  large,  hard 
cataract,  without  much,  or  any,  bruising  of  the  iris.  Moreover,  if  the 
uj)per  eyelid  hangs  down  sufiiciently  to  cover  the  upper  third  of  the 
cornea  no  unsightluiess  or  inconvenience  will  be  produced  by  so  large 
an  iridectomy.  It  will  be  difierent,  if  the  aperture  between  the  eyeHds 
is  wide,  so  that  the  whole  of  the  cornea  is  exposed,  for  then  the  very 
extensive  artificial  pupil  may  give  rise  to  a  considerable  feeling  of 
glare,  and  also  diminish  the  acuity  of  the  vision  by  irregular  refraction 
at  its  periphery,  which  gives  rise  to  considerable  circles  of  diifusion. 
But  whatever  the  extent  of  the  iridectomy,  we  should  always  be  very 
careful  to  remove  the  iris  quite  close  to  its  insertion,  so  that  no  little 
portions  remain  behind  in  the  section,  for  these  may  retard  the  union  of 
the  wound,  be  productive  of  much  irritation,  and  give  rise  to  prolapse, 
which  may  subsequently  prove  very  troublesome,  or  even  dangerous  to 
the  eye. 

3.  Iiaceration  of  the  Capsule. — The  capsule  is  to  be  freely  divided  with 
the  pricker  by  two  successive  lacerations.  The  one  is  to  commence  at 
the  lower  edge  of  the  pupil,  or  even  a  little  beneath  it,  and  extend  up- 
wards along  its  inner  side,  the  other  along  its  outer  side.  Both  incisions 
should  reach  quite  up  to  the  periphery  of  the  lens  exposed  by  the  iridec- 
tomy. If  there  are  slight  adhesions  between  the  ii'is  and  the  pupil, 
these  may  be  readily  divided  by  passing  the  instrument  slightly  be- 
neath the  edge  of  the  pupil.  The  capsule  should  also  be  gently 
lacerated  at  its  periphery,  corresponding  to  the  line  of  incision.  Through- 
out, the  edge  of  the  instrument  should  be  turned  in  a  somewhat 
slanting  direction,  and  not  be  pressed  firmly  backwards,  indeed  it 
should  be  used  with  great  delicacy  and  lightness,  otherwise  displace- 
ment of  the  lens  into  the  vitreous  humour  may  easily  occur. 

4.  Removal  of  the  Lens. — During  the  earher  period  of  performing  his 
new  operation.  Von  Graefc  was  in  the  habit  of  assisting  the  progress  of 
the  lens  by  pressing  upon  the  upper  portion  of  the  sclerotic  with  a 
broad  curette,  and  aiding  this  by  a  counter- pressure  with  the  forceps 


VON  graefe's  extraction.  201 

below  the  cornea.  When  the  edge  of  the  lens  had  once  presented 
itself  in  the  section,  its  delivery  was  still  more  assisted  by  gliding 
the  curette  in  a  lateral  direction  along  the  sclerotic  to  the  angles  of 
the  incision  ("  Schlitten-manccuvre  "  of  Von  Graefe).  It  was  found, 
however,  that  the  removal  of  the  lens  was  often  difficult  without 
exerting  a  dangerous  degree  of  pressure  and  that  occasionally  it  was 
necessary,  in  order  to  extract  the  lens,  to  pass  in  a  scoop,  or  a  peculiarly 
shaped  hook,  devised  by  Von  Graefe. 

Lately  he  has  substituted  for  this  manceuvre  the  use  of  a  vulcanite 
curette,  which  aids  the  removal  of  the  lens  by  being  pressed  against  the 
lower  portion  of  the  cornea.  It  is  to  be  used  in  the  following  manner  : 
— The  eye  is  to  be  fixed  with  the  forceps,  which  are  to  be  placed  not 
directly  below  the  cornea,  as  they  wo  aid  then  interfere  somewhat  .with 
the  manipulation  of  the  curette,  but  slightly  to  the  inner  or  outer  side. 
The  curette  is  then  to  be  placed  upon  the  lower  edge  of  the  cornea,  and 
pressed  slightly  backwards  and  upwards,  so  as  to  cause  the  upper  edge 
of  the  lens  to  present  itself  in  the  section  ;  the  pressure  is  then  to  be 
made  directly  backwards,  in  order  that  the  lens  may  be  rotated  round 
its  transverse  axis,  and  tilted  well  forward  into  the  incision.  When 
this  has  occurred,  its  exit  is  gently  aided  by  pushing  the  curette  slowly 
upwards  over  the  surface  of  the  cornea,  so  that  it  follows  step  by  step 
the  delivery  of  the  lens.  If  it  is  found  that  portions  of  the  lower  cortical 
substance  are  stripped  off,  and  are  inclined  to  lag  behind,  the  curette 
should  be  drawn  a  little  back  again,  and  the  fragments  of  cortex  pushed 
along  after  the  body  of  the  lens,  and  in  this  way  the  whole  cataract 
may  generally  be  removed.  If  small  portions  of  lens  matter  remain 
behind,  they  should  be  coaxed  out  by  again  passing  the  curette  over  the 
cornea,  and  pushing  on  the  fragments  in  front  of  the  instrument.  The 
object  of  making  the  curette  of  vulcanite  instead  of  silver  is  that  it  is 
more  resihent,  and  the  degree  of  pressure  can  therefore  be  regulated 
Avith  the  greatest  nicety,  and  its  touch  is  moreover  more  agreeable  to 
the  cornea.  The  vulcanite,  has,  however,  the  disadvantage  of  being 
very  brittle,  so  that  it  breaks  very  readily.  For  this  reason  I  have 
lately  preferred  Weiss's  tortoise-shell  curette,  which  offers  all  the  advan- 
tages of  the  vulcanite,  without  its  brittleness. 

The  loss  of  vitreous  humour  has  diminished  very  considerably  since 
Von  Graefe  substituted  the  latter  mode  of  removing  the  lens  (by  press- 
ing from  below)  for  the  "  Schlitten-manoeuvre,"  indeed  in  the  last  230 
operations  he  has  only  lost  vitreous  humour  in  nine  cases,  which  gives 
less  than  4  per  cent.  In  three  of  these  the  vitreous  humour  was,  more- 
over, fluid.  If  this  occurs,  the  vitreous  may  escape  directly  the  section 
is  finished,  and  even  before  it  is  attempted  to  excise  a  portion  of  iris. 
In  such  a  case  it  is  best  to  excise  a  portion  of  iris,  if  this  can  be  done 
without  a  very  great  loss  of  vitreous,  and  then  to  remove  the  lens  in 


262  DISEASES  OF   THE   CRYSTALLINE  LENS. 

its  capsule  by  passing  Critcliett's  scoop  behind  it  into  the  vitreous 
humour,  and  lifting'  it  out.  A  considerable  quantity  of  vitreous  will  of 
course  escape,  but  subsequent  inflammation  is  likely  to  be  far  less 
severe  if  the  entire  lens  is  removed  in  its  capsule,  than  if  more  or  less 
considerable  fragments  of  lens  substance  and  capsule  remain  behind. 

Several  of  the  best  operators  still  differ  in  opinion  as  to  the  advan- 
tage of  making  the  section  in  the  sclerotic  or  in  the  cornea,  whilst 
Graefe  prefers  the  former,  Critchett  and  Arlt  are  in  favour  of  the  latter 
proceeding.  I  think  that  the  exact  line  and  size  of  the  incision  should 
vary  with  the  size  and  hardness  of  the  nucleus  and  with  the  size  of  the 
cornea.  If  the  nucleus  is  la.rge  and  firm,  and  the  diameter  of  the 
cornea  small,  the  section  should  be  made  slightly  more  in  the  sclerotic, 
the  puncture  and  counter-puncture  being  also  somewhat  lower,  for 
thus  we  shall  gain  a  larger  section,  and  the  delivery  of  the  lens  will  be 
easy  and  free  from  all  squeezing  and  bruising  of  the  parts.  If  the 
section  is  made  in  the  cornea,  and  more  especially  if  a  portion  of 
cornea  is  left  standing  at  the  top,  the  exit  of  the  lens  is  often  difficalt 
and  laboured,  and  accompanied  by  a  good  deal  of  bruising  of  the  parts 
and  stripping  off  of  the  surface  matter  of  the  lens,  which,  if  it  remains 
behind,  may  set  up  very  considerable  irritation.  Moreover,  the  upper 
edge  of  the  lens  may  be  caught  behind  the  portion  of  the  cornea  which 
has  been  left  standing,  and  be  firmly  wedged  in  between  it,  or  the  lens 
may  even  be  displaced  upwards  behind  the  sclerotic.  This  is  the  more 
apt  to  occur  if  the  first  pressure  which  is  made  with  the  curette  upon 
the  lower  portion  of  the  cornea  is  not  made  backwards  and  upwards, 
but  only  upwards,  for  then  the  lens  will  be  pushed  directly  upwards, 
and  may  become  lodged  behind  the  upper  portion  of  the  cornea.  The 
object  of  the  backward  pressure  upon  the  lower  portion  of  the  lens  is 
to  tilt  its  upper  edge  into  the  section,  for  when  it  has  once  gained  this 
position  the  escape  of  the  lens  is  easy  enough,  providing  the  section  be 
of  a  sufficient  size.  My  own  experience,  I  must  admit,  is  greatly  in 
favour  of  the  sclerotic  section  lying  in  the  sclero-corneal  junction  or 
very  slightly  beyond  it.  Where  a  considerable  section  is  required,  I 
prefer  to  obtain  this  rather  by  making  the  puncture  and  counter-punc- 
ture lower,  than  by  making  the  section  more  in  the  sclerotic,  for  in  the 
latter  case  there  is  always  a  greater  risk  of  loss  of  vitreous. 

The  after  treatment  of  this  operation  is  generally  extremely  simple. 
Liebreich's  bandage  should  be  applied  directly  after  the  operation,  and 
if  any  severe  pain  should  arise  in  the  course  of  the  day,  cold  water 
dressing  (frequently  changed)  should  be  applied,  care  being  taken  that 
it  is  not  persisted  in  too  long.  If  the  pain  does  not  yield  to  this  treat- 
ment, a  leech  or  two  should  be  applied  to  the  temple.  On  the  second  day 
atro])inc  drops  should  be  prescribed.  The  patient  may  generally  leave 
his  bed  on  the  second  or  third  day,  but  this  will  depend  upon  individual 


VON  graefe's  extraction.  263 

circumstances,  and  upon  tlie  fact  as  to  whether  he  can  have  pi-oper 
supervision.  With  some  patients  it  is  advisable  to  permit  their  leaving 
the  bed  even  the  day  after  the  operation,  but  it  is  always  wiser  to  eiT 
on  the  side  of  safety.  The  general  rules  laid  down  for  the  after  treat- 
ment of  flap-extraction  also  apply  to  Von  Graefe's  operation. 

The  success  of  this  operation  has  been  so  great,  that  most  ophthal- 
mologists, amongst  whom  I  may  mention  Mr,  Bowman,  have  entirely 
abandoned  the  scoop  extraction,  and  even  to  a  great  extent  the  flap 
operation.  My  own  experience  of  it  is  also  extremely  favourable,  and 
I  prefer  it  gr'catly  to  every  other  mode  of  extraction. 

Dr.  Taylor,  of  Nottingham,  has  operated  by  a  method  somewhat 
similar  to  that  of  Von  Graefe  (but  quite  independently  of  him)  since 
the  summer  of  18G5,  indeed  both  appear  to  have  bcgvm  about  the  same 
time.  In  No.  9  of  the  OpMhalmic  Bevieio  (April,  18G6),  Dr.  Taylor 
says  : — "  I  have  also,  in  certain  cases  where  the  results  of  sclero-choroi- 
ditis  posterior,  extensive  atheroma  of  the  vessels,  staphyloma,  or  other 
disease  of  the  eyeball,  render  it  unsafe  to  reduce  tension  so  suddenly  or 
completely  as  is  done  by  the  ordinary  flap  operation,  endeavoured  to 
obviate  the  dangers  of  escape  of  vitreous,  haemorrhage,  and  subsequent 
suppuration  of  the  eyeball  by  a  modification  of  Schuft's  operation — 
premising  an  iridectomy  as  above,  and  making  the  incision  with  a  small 
ground  down  cataract- knife,  entered  in  the  cornea  and  sclerotic  junction, 
and  emerging  at  a  comiter-pmicture,  so  as  to  incise  a  little  more  than 
the  upper  third  of  the  cornea,  the  openijig  being  well  back,  and  larger 
than  the  large  one  sometimes  required  in  Schuft's  operation.  The  eye 
may  be  safely  fixed  throughout  the  operation.  The  flap  cannot  be 
tui'ned  down;  and  yet,  if  the  posterior  lip  of  the  wound  be  gently 
pressed  back,  the  lens  may  be  coaxed  out  without  passing  any  instru- 
ment into  the  eye." 

I  will  now  briefly  mention  the  principal  arguments  which  may  be 
advanced  in  favour  of  or  against  the  difierent  operations  for  senile 
cataract.  In  doing  this  I  shall  confine  myself  to  the  flap  extraction, 
the  scoop  operation,  and  Von  Graefe's  new  modified  linear  extraction. 

There  cannot  be  any  doubt  that  the  common  flap  extraction  is  the 
most  perfect  operation  of  all,  when  it  tui'ns  out  perfectly  successful.  It 
is  nearly  free  from  pain ;  it  does  not  in  the  least  interfere  with  the 
appearance  of  the  eye  ;  the  pupil  remains  central  and  moveable ;  the  sight 
is  perfect,  and  is  not  at  all  deteriorated  and  confused  by  circles  of 
difiusion  upon  the  retina,  which  are  always  more  or  less  present  when 
an  iridectomy  has  been  performed.  It  must,  however,  be  confessed  that 
these  gi-eat  advantages  are  often  more  than  counterbalanced  by  the 
considerable  dangers  which  beset  the  operation.  On  account  of  the 
great  size  of  the  flap,  there  is  miich  risk  of  the  vitality  of  the  cornea 
becoming  impaired,  and  of  its  undergoing  partial  or  even  diffuse  sup- 


264  DISEASES  OF   THE   CRYSTALLINE  LENS. 

puration,  which  may  be  accompanied  by  suppurative  iritis  or  irido- 
choroiditis.     Again,  prolapse  of  the  iris   is  a  not  unfrequent  complica- 
tion, proving  a  source  not  only  of  gi^eat  annoyance  and   irritation,  but 
even  of  danger  to  the  eye.     The   after-treatment  also   demands  much 
care  and  attention — more,  indeed,  than  can  generally  be  bestowed  in 
an  Hospital,  especially  in  a  General  one,  with  no  special  nurses  or 
ophthalmic  wards.     Now,  in  the   scoop  extraction,  these  two  principal 
dangers — suppuration  of  the  cornea  and  prolapse  of  the  iris — are  nearly 
completely  eliminated.      On  account  of  the  position  and  shape  of  the 
incision,  suppuration  of  the  cornea,  even  of  Hmited  extent,  is  rare,  and 
a  prolapse  of  the  iris  can  only  be  slight,  and  is  confined  to  the  angles  of 
the  section.      Moreover,  chloroform  may  be  administered  without  any 
fear.     But  it  must  be  admitted  that  iritis,  chronic  and  insidious  ii-ido- 
choroiditis,  inflammation  of  the    intra-capsular  cells,  and   secondary 
cataract,  are  more  common  than  in  flap  extraction.      Von  Graefe's 
operation,  however,  offers  all  the  advantages  of  the   scoop  extraction, 
viz.,  the  administration  of  chloroform,  the  linear  shape  of  the  incision, 
involving  but  a  small  portion  of  the   cornea  and  the  iridectomy,  and 
yet  one  more  most  important  one,  the  power  of  removing  the  lens  with- 
out any  traction  instrument.     It  is  in  my  opinion  to  be  preferred,  as  a 
rule,  to  any  other  mode  of  extraction,  more  especially    in   Hospital 
practice,  as  the  patient  requires  far  less  watching  and  attendance,  and 
the  after  treatment  is  extremely  simple.     The  confinement  to  the  bed 
and  house  is  also  much  shorter  than  in  flap  extraction.      I  think  it  is 
especially  indicated  in  very  feeble,  decrepid,  nervous,  and  unmanageable 
patients,  or   those   sufiering  from   severe    cough,  or  bronchitis ;    also 
if  the  pupil  is  adherent,  or  small  and  rigid,  so  that  it  dilates  but  im- 
perfectly under  the  influence  of  atropine,  or  if  the  cataract  is  complicated 
with  some  choroidal  or  retinal  lesion.     It  is  also  the  safest  operation  for 
diabetic  cataract,  for  in  the  flap  extraction  (even  with  a  preliminary 
iridectomy),  there  is  always  some  risk  of  suppuration  of  the  cornea  in 
these  patients,  as  they  are  generally  in  a  very  feeble  state  of  health. 
As  the  iris  is  exceptionally  impatient  of  irritation  and  bruising  in  cases 
of  diabetes,  it  may  be  advisable,  in  order  to  secure  the  greatest  im- 
m.unity  from  this  danger,  to  make  a  double  iridectomy,  viz.,  upwards 
and  downwards,  so  as  to  get  a  broad  vertical  pupil,   the  two  opposite 
portions  of  the  iris  being  thus  completely  cut  off"  from  each  other.     I 
am  sometimes  asked  by  medical  practitioners  and  students  which  opera- 
tion I  consider  the  easiest  and  safest  for  an  inexperienced  operator.     I 
think  that,  all  things  considered,  the  downward  flap  operation  is  the 
easiest,  for  when  the  section  has  been  successfully  completed,  the  chief 
danger  and  difficulty  are  past ;  whereas  in  the  modified  linear  extraction 
the  iridectomy  is   superadded.      I   should,  therefore,   recommend  that 
when  the  surgeon  has  operated  several  times  by  the   lower  flap  extrac- 


RECLINATION.      DR^ISION.  2G5 

tion,  and  has  acquired  some  experience  and  dexterity,  he  shoukl  pass  on 
to  the  upper  flap  extraction,  and  Von  Graefe's  operation.  The  only- 
two  points  in  the  hitter  which  demand  practice,  care,  and  dexterity,  are 
the  incision  and  the  removal  of  the  lens.  If  the  section  is  too  small, 
the  delivery  of  the  lens  will  be  difficult  and  forced,  and  will  necessitate 
enlargement  of  the  incision,  considerable  pressure  upon  the  eyeball,  or 
the  introduction  of  some  form  of  traction  instrument.  If,  on  the  other 
hand,  it  is  too  large  and  lies  too  far  in  the  sclerotic,  there  is  imminent 
risk  of  losing  much  vitreous  humour,  perhaps  even  before  the  removal 
of  the  lens  is  attempted.  Considerable  nicety  and  care  are  also  required 
in  coaxing  out  the  lens  by  pressing  upon  the  cornea  with  the  curette, 
for  if  this  is  roughly  and  clumsily  done  the  hyaloid  may  be  ruptured, 
the  vitreous  escape,  and  the  lens  will  probably  be  pushed  somewhat 
aside,  and  a  scoop  will  have  to  be  employed  for  its  removal. 

9.— RECLINATION  OR  COUCHING. 

I  only  mention  this  operation  to  state  that,  in  my  opinion,  it 
should  be  completely  abandoned.  Although  it  may  appear  to  be 
temporarily  successful,  it  has  been  found  that  ultimately  about  50  per 
cent,  of  the  eyes  have  been  lost  from  chronic  irido-choroiditis,  etc.  It 
is  performed  in  the  following  manner : — The  pupil  having  been  widely 
dilated  by  atropine,  a  curved  couching  needle,  with  its  convex  surface 
tm-ned  upwards,  is  passed  through  the  sclerotic  at  the  temporal  side,  a 
little  distance  from  the  cornea,  and  somewhat  below  its  horizontal 
diameter.  When  the  needle  has  penetrated  the  sclerotic,  it  is  to  be 
turned  so  as  to  bring  its  convex  surface  parallel  to  the  iris,  behind 
which  it  is  to  be  carried  to  the  edge  of  the  papil,  and  then  passed 
diagonally  across  to  the  opposite  side  of  the  anterior  chamber.  When 
its  point  has  arrived  near  the  inner  and  upper  edge  of  the  pupil,  the 
handle  of  the  instrument  is  to  be  hghtly  tilted  upwards  between  the 
fingers,  and  the  lens  slowly  depressed  by  the  concave  surface  of  the 
needle  into  the  lower  and  outer  portion  of  the  vitreous  humour.  It 
should  be  kept  by  the  needle  in  this  position  for  a  few  moments,  in 
order  to  prevent  its  reascending.  The  needle  is  then  to  be  slightly 
rotated,  in  order  to  disentangle  its  point,  and  drawn  back  to  the  point 
of  entrance.  The  operator  should  wait  for  a  few  moments  to  see  if  the 
lens  rises  up  again,  in  which  case  the  depression  is  to  be  repeated. 

10.— DIVISION  OR  SOLUTION  OF  CATARACT. 

This  operation  is  more  especially  indicated  in  the  cortical  cataract 
of  children  and  of  young  persons  up  to  the  age  of  twenty,  or  even 
twenty- five]   also   in  those   forms   of  lamellar  cataract  in  which  the 


266  DISEASES  OF   THE  CRYSTALLINE  LENS, 

opacity  is  too  extensive  to  allow  of  rtmcli  benefit  being  derived  from  an 
artificial  pupil.  After  the  age  of  thirty-five  or  forty,  the  lens  is  gene- 
rally too  hard  to  undergo  anything  but  very  slow  absorption,  even  after 
frequent  repetitions  of  the  operation ;  the  iris  is  also  more  impatient  of 
irritation  and  pressure,  so  that  the  danger  of  setting  up  iritis  is  much 
increased ;  and  there  are  other  operations  which  are  much  to  be  pre- 
ferred for  cataracts  occurring  at  this  time  of  life.  In  infants  and  young 
children  an  operation  for  cataract  should  not  be  unnecessarily  post- 
poned, as  the  presence  of  the  cataract  is  very  apt  in  infancy  to  give 
rise  to  nystagmus,  and  to  that  form  of  amblyopia  which  is  dependent 
upon  non-use  of  the  eyes,  and  which  is  similar  in  character  to  that  so 
often  met  with  in  strabismus. 

The  object  of  the  operation  of  division  is  to  lacerate  the  anterior 
capsule  with  a  fine  needle,  so  as  slightly  to  break  up  the  surface  of  the 
lens  and  to  permit  the  aqueous  humour  to  come  into  contact  with  the 
lens  substance,  which,  imbibing  the  fluid,  softens,  and  becomes  gra- 
dually absorbed.  The  time  required  for  the  absorption  varies  with  the 
age  of  the  patient  and  the  consistence  of  the  cataract.  In  infants  and 
young  children  the  lens  is  often  absoibed  in  from  six  to  ten  weeks,  and 
one  operation  may  suffice  for  this  purpose.  But  in  adults  it  may  have 
to  be  repeated  several  times,  and  in  them  great  care  should  be  taken 
not  to  divide  the  capsule  and  the  lens  too  freely  at  one  sitting,  for  this 
will  cause  great  swelling  of  the  lens  substance,  or  the  exit  of  con- 
siderable flakes  into  the  anterior  chamber,  and  either  of  these  causes 
may  set  up  severe  iritis  or  irido-cyclitis.  The  same  caution  is  neces- 
sary in  cases  of  lamellar  cataract,  because  in  these,  a  large  portion  of 
the  lens  is  transparent  and  of  normal  consistence,  and  will  therefore 
imbibe  much  aqueous  humour  and  swell  up  very  considerably. 

Prior  to  the  operation  the  pupil  should  be  widely  dilated  with 
atropine.  The  patient,  more  especially  if  a  child,  should  be  placed 
under  the  influence  of  chloroform.  Infants  should  be  firmly  rolled  in 
a  blanket  or  sheet  so  that  their  movements  may  be  controlled.  The 
eyelids  are  to  be  kept  apart  with  the  spring  speculum,  and  the  eye 
fixed  with  a  pair  of  forceps.  A  very  fine  needle  is  then  to  be  passed 
somewhat  obliquely  through  the  outer  and  lower  quadrant  of  the 
cornea,  at  a  point  lying  well  within  the  dilated  pupil,  so  that  the  iris 
may  not  be  touched  by  the  stem  of  the  needle  during  the  breaking  up 
of  the  lens.  The  track  of  the  corneal  wound  must  not  be  too  slanting, 
otherwise  its  channel  will  be  too  long,  and  the  tissue  of  the  cornea  will 
be  stretched  and  bruised  during  the  working  of  the  needle,  and  this 
may  produce  an  opacity  of  the  cornea ;  nor  must  it  be  too  straight, 
otherwise  the  aqueous  humour  might  easily  escape.  The  size  and 
number  of  the  incisions  in  the  capsule  must  vary  with  the  amount  of 
effect  that  wo  desire.     If  the  latter  is  to  be  but  very  slight,  a  single 


DWISION  OF   CATARACT.  2G7 

small  horizontal  or  vertical  tear  may  suffice,  or  a  crucial  incision  of 
limited  extent  may  be  made.  But  if  we  desire  a  more  considerable 
effect,  more  especially  in  tlie  cortical  cataract  of  children,  the  incisions 
must  be  more  extensive,  or  the  superficial  portion  of  the  lens  is  to  be 
gently  broken  up  or  comminuted  by  a  series  of  short  superficial  inci- 
sions, which  converge  towards  the  centre  of  the  cataract.  In  infants 
and  young  children  the  needle  may  be  far  more  freely  used  than  in 
adults,  or  in  cases  of  lamellar  or  partial  cataract.  In  such,  it  is  always 
safer  to  repeat  the  operation,  even  several  times,  than  to  do  too  much 
at  one  sitting.  It  may  be  repeated  at  intervals  of  three  or  four  weeks, 
if  it  is  found  that  the  absorption  has  become  arrested  or  progresses  but 
very  slowly;  but  all  irritability  and  redness  of  the  eye  should  have 
disappeared  before  the  needle  is  again  introduced.  If  the  opening  in 
the  capsule  is  too  large,  or  the  cataract  broken  up  too  freely,  the  lens 
will  imbibe  much  aqueous  humour,  and,  swelling  up  very  considerably, 
will  press  upon  the  ii-is  and  ciliary  body,  and  may  thus  set  up  severe 
iritis  or  irido-cyclitis  ;  or  if  the  incisions  in  the  capsule  are  too  exten- 
sive, fragments  of  lens  substance  may  fall  into  the  anterior  chamber, 
and  there  set  up  great  irritation. 

The  needle  used  for  this  operation  should  be  very  small ;  j,. 
its  cutting,  spear-shaped  point  should  only  extend  to  about 
■jig-th  or  Joth  of  an  inch  from  the  end,  and  the  stem  should  be 
cylindrical,  so  that  the  aqueous  humour  may  be  retained 
throughout  the  operation.  I  always  use  Bowman's  fine  stop 
needle  (Fig.  39),  which  fulfils  all  these  indications. 

The  after-treatment  is  generally  very  simple.  The  pupil 
should  be  kept  widely  dilated  with  atropine,  so  that  the  iris 
cannot  be  pressed  upon  by  the  swollen  lens  or  any  flakes 
that  may  have  fallen  into  the  anterior  chamber.  A  bandage 
should  be  worn  for  the  first  twenty-four  hours,  and  the 
patient  should  be  kept  in  a  somewhat  darkened  room  for 
the  first  d„/  or  two,  especially  if  there  is  much  reaction.  Gene- 
rally, however,  this  is  but  slight,  the  eye  only  looking  flushed,  and 
watering  somewhat  on  exposure  to  bright  light.  My  friend,  Mr.  Law- 
son,  has  even  successfully  operated  by  this  method  upon  some  cases  of 
monocular  cortical  cataract  in  adults  (between  the  ages  of  twenty  and 
thirty),  and  treated  them  throughout  as  out-patients.  These  were, 
however,  exceptional  cases,  in  which  it  was  absolutely  necessary  that 
the  patients  should  follow  their  employment.  In  order  to  expedite  the 
cure,  which  is  often  of  consequence  in  patients  from  the  country,  it  is  a 
very  good  plan,  after  the  lens  matter  has  become  softened  by  the 
admission  of  the  aqueous,  to  remove  the  whole  cataract  by  a  broad  linear 
incision.  In  children  this  may  generally  be  done  within  a  week  after 
the  division,  and  thus  the  sight  may  be  restored  in  a  few  days,  whereas, 


268  DISEASES  OF   THE  CRYSTALLINE   LENS. 

otherwise,  many  weeks  or  even  months  would  have  elapsed  before  the 
cataract  would  have  been  entirely  absorbed.  The  same  proceeding 
may  be  employed  in  cases  of  partial  cataract,  the  transparent  portion 
of  the  lens  being  made  opaque,  and  softened  by  the  introduction  of  the 
needle.  This  mode  of  operation  has  been  very  successfully  practised 
and  much  advocated  by  Mr.  Bowman,  who  also  often  advantageously 
employs  the  suction  syringe  for  the  removal  of  the  softened  lens  after 
it  has  been  previously  broken  up  by  the  needle. 

If  symptoms  of  irritation  and  inflammation  should  set  in  after  the 
operation  of  division,  and  they  do  not  readily  yield  to  antiphlogistics, 
but  increase  in  severity,  and  more  especially  if  the  tension  of  the  eye- 
ball is  augmented,  the  cataract  should  be  at  once  removed  through  a 
good-sized  linear  incision,  made  near  the  periphery  of  the  cornea  with 
an  iridectomy  knife.  This  is  also  to  be  done  if  the  capsule  has  been 
too  freely  divided,  and  the  nucleus  or  considerable  portions  of  lens 
substance  have  fallen  into  the  anterior  chamber,  and  are  setting  up 
much  irritation.  If  the  lens  is  so  firm  that  it  cannot  all  be  readily 
removed  through  the  linear  section,  it  will  be  wiser  to  combine  an 
iridectomy  with  it,  than  to  endeavour  to  remove  the  portions  of  lens  by 
repeated  introductions  of  the  curette  into  the  anterior  chamber.  An 
iridectomy  is  also  indicated  if  the  increase  of  tension  has  existed  for 
some  little  time,  and  if  the  perception  of  light  and  the  extent  of  the 
field  of  vision  are  markedly  deteriorated. 

Two  special  forms  of  inflammation  may  follow  the  operation,  and 
endanger  the  safety  of  the  eye.  In  the  one,  the  inflammation  is  chiefly 
plastic  or  purulent  in  character.  The  iritis  or  irido-cyclitis  is  accom- 
panied by  plastic  exudations  behind  the  iris,  and  into  the  vitreous 
humour,  leading  eventually  in  all  probability  to  chronic  irido- choroiditis 
and  atrophy  of  the  globe.  In  the  other  form,  the  inflammation  is  of  a 
serous  nature,  giving  rise  to  an  increased  secretion  of  the  vitreous 
humour,  and  an  augmentation  of  the  intra-ocular  pressure — in  a  word, 
to  a  glaucomatous  condition  of  the  eyeball,  which  may  cause  irre- 
trievable destruction  of  the  sight  if  timely  relief  be  not  afforded. 

As  these  inflammatory  complications  are  most  apt  to  occur  in 
adults  above  the  age  of  fifteen  or  twenty,  more  especially  if  the 
cataract  is  only  partial  or  of  a  lamellar  nature.  Von  Graefe  advises 
that  in  such  cases,  or  if  any  posterior  synechise  exist,  an  upward  iri- 
dectomy should  be  made  a  few  weeks  before  the  operation  of  division. 
By  so  doing,  plenty  of  room  will  be  afforded  for  the  swelling  up  of  the 
lens,  and  if  fragments  have  fallen  into  the  anterior  chamber,  they  will 
produce  far  less  irritation. 


OPERATIONS  FOR  LAMELLAR  CATARACT. 


2m 


11.— OPERATIONS  FOR  LAMELLAR  OR  ZONULAR 
CATARACT. 

Wlieu  describing  the  natirre  of  lamellar  cataract,  I  mentioned  that 
in  those  cases  in  which  a  sufficiently  broad  margin  of  transparent  lens 
substance  exists,  great  improvement  of  vision  may  often  be  attained 
by  dilating  the  pupil  by  atropine.  A  glance  at  the  accompanying 
figures  will  explain  this.  In  Fig.  40,  a  represents  the  undilated  pupil 
occupied  by  the  opacity  h,  which  extends  beneath  the  iris  as  far  as  the 
dotted  line  c,  where  the  transparent  margin  d  commences.     As  the 


Fig.  40. 


Fig.  41. 


latter  is  completely  covered  by  the  iris,  the  rays  of  Kght  can  only  pass 
through  the  central  opaque  portion ;  hence  the  indistinctness  of  vision. 
But  when  the  pupil  is  dilated  (Fig.  41)  the  transparent  margin  of  the 
lens  d  is  uncovered,  and  the  rays  can  now  pass  through  it  to  the 
retina.  This  fact  is  of  great  practical  importance,  for  it  famishes  us 
with  a  very  valuable  indication  as  to  the  treatment  of  such  cases  of 
lamellar  cataract,  for  we  may  often  succeed  in  restoring  excellent 
vision  by  simply  making  an  artificial  pupil  without  operating  upon  the 
lens  itself.  Such  a  proceeding  possesses  very  marked  advantages  over 
any  operation  for  the  removal  of  the  lens  ;  for  the  patient  retains  the 
power  of  accommodation,  and  is  freed  from  the  necessity  of  w^earing 
cataract  glasses,  which  are  not  only  inconvenient,  but  also  unsightly, 
more  especially  in  youthful  individuals.  The  artificial  pupil  may  be 
made  either  by  means  of  an  iridectomy  or  an  iridodesis.  The  former 
operation  has  the  disadvantage  that  the  base  of  the  artificial  pupil 
(Fig.  42)  is  opposite  the  periphery  of  the  lens  d,  and  may  therefore 
give  rise  to  a  certain  indistinctness  of  vision,  on 
account  of  the  rays  being  irregularly  refi-acted  by 
the  edge  of  the  cornea  and  lens,  circles  of  diffusion 
on  the  retina  being  thus  produced.  In  order  to 
diminish  this  defect,  the  iridectomy  should  be  but 
small.  In  most  cases  I  think  Mr.  Critchett's  opera- 
tion of  iridodesis  is  to  be  preferred.  A  considerable 
portion  of  iris  should  be  drawn  out,  in  order  that  the 
entire  pupil  may  be  drawn  near  the  margin  of  the 
cornea,  for  the  Lris  will  thus  cover  a  large  extent  of 
the  opaque  portion  of  the  lens.  There  will  thus 
result  a  pupil  Like  that  in  Fig.  43,  having  its  apex, 


Fisj.  -12. 


Fis.  43. 


270  DISEASES  OP   THE  CRYSTALLINE  LENS. 

and  not  its  base,  opposite  the  clear  portion  of  the  lens.  Mr.  Critchetfc 
has  also  in  some  cases  obtained  great  improvement  of  sight  by  making 
a  second  iridodesis  close  to  the  other,  thus  gaining  a  somewhat  broader 
pupil,  and  admitting  more  light. 

If  the  transparent  margin  in  lamellar  cataract  is  not  sufficiently 
broad  or  clear  to  admit  of  much  improvement  of  vision  by  an  artificial 
pupil,  the  lens  itself  must  be  operated  upon  either  by  division  with  or 
without  iridectomy,  or  by  Von  Graefe's  operation. 

In  persons  under  25,  I  think  it  best  slightly  to  divide  the  lens  with 
a  needle,  and  to  repeat  this  several  times,  and  then,  Avhen  the  whole 
lens  has  become  opaque  and  softened,  to  remove  it  through  a  large 
linear  incision,  or  with  the  suction  curette.  It  is  never  wise  to  operate 
upon  both  eyes  at  the  same  time,  for  in  some  cases  eyes  affected  with 
lamellar  cataract  are  extremely  irritable,  and  considerable  irido-choroi- 
ditis,  with  or  without  sloughing  of  the  cornea,  may  supervene  and 
destroy  the  eye.  If  this  has  occurred  in  the  one  eye,  we  should  be 
greatly  upon  our  guard  in  operating  upon  the  second  at  a  subsequent 
period,  or  devise  some  other  mode  of  operating.  In  persons  above 
the  age  of  25,  I  have  succeeded  very  well  in  removing  the  lens  by  Von 
Graefe's  operation. 

12.— OPERATIONS  FOR  TRAUMATIC  CATARACT. 

If  the  wound  in  the  lens  is  of  but  slight  extent,  and  the  patient 
young,  the  cataract  may  be  left  to  absorption  if  no  symptoms  of  in- 
flammation set  in.  The  pupil  should  be  kept  widely  dilated  with 
atropine,  and  the  condition  of  the  eye  carefully  watched.  If  inflam- 
matoi-y  symptoms  supervene,  it  may  be  necessary  to  remove  the  lens 
by  linear  extraction,  more  especially  if  it  swells  up  considerably,  or 
laroe  portions  have  fallen  into  the  anterior  chamber  and  are  setting  up 
ii^iitation.  This  operation  should  also  be  at  once  performed  if  the 
w^ound  in  the  lens  has  been  considerable,  so  that  the  latter,  imbibing 
much  aqueous  humour,  becomes  rapidly  swollen  and  presses  ujDon  the 
iris  and  ciliary  body.  The  simple  linear  extraction  will  generally  suffice 
if  the  lens  is  so  softened  that  it  will  readily  escape  through  the 
incision.  But  if  the  nucleus  or  the  greater  portion  of  the  lens  is  still 
firm,  it  may  be  more  advisable  to  make  a  large  iridectomy,  in  order  to 
afford  more  room  for  the  swelling  of  the  lens,  and  then  to  leave  the 
latter  to  undergo  a-bsorption,  which  will  now  be  attended  by  far  less 
risk.  In  those  cases  in  which  great  swelling  of  the  lens  is  accompanied 
by  severe  inflammation,  it  will  be  best  to  make  a  large  iridectomy,  and 
remove  the  cataract  either  with  or  without  the  aid  of  the  scoop.  If 
there  is  much  soft  matter,  this  may  be  removed  with  the  suction  syiinge, 
although  I  am  rather  afraid  of  its  use  in  such  cases,  especially  if  there 


OPERATIONS  FOR  TRAUMATIC  CATARACT.  271 

is  any  iritis  or  irido-choroiditis,  as  it  may  easily  produce  hypera^mia  ex  / 

vacuo  of  tlie  inner  tnuics  of  the  eyeball.     If  a  foreign  body — e.g.,  a   jiC^^^  Jf/'22 
chip  of  steel,  glass,  or  gun-cap — is  lodged  in  the  lens,   it  is  wiser  to      />^  Jv^T,./'' 
endeavour  to  remove  it,  together  with  the  lens.     This  should  be  done      ; 
by  introducing  a  scoop  well  behind  the  foreign  body  and  lifting  it  out ;  ^      ^^•^ 

for  if  we  permit  the  lens  to  undergo  absorption,  the  foreign  body  will  a 

at  last  become  disengaged  and  fall  down  into  the  anterior  or  posterior  "^  jTo^i 

chamber,   and  probably   sot  up  sevei'e   and  even  perhaps  destructive       '^ ^  ^tj^n^ 
inflammation.     The  situation  of  a  bit  of  metal  in  the  lens  may  often 
be  recognised  by  the  aid  of  the  oblique  illumination,  when  we  may 
observe  a  little  brown  spot  in  the  lens,  or  a  little  dark  line  showing  the 
track  of  the  foreign  body. 

If  the  foreign  body  has  passed  through  the  lens  and  is  lodged  in 
the  vitreous  humour,  retina,  or  choroid,  great  attention  must  be  paid 
to  the  condition  of  the  eye,  as  severe  and  destructive  inflammation  is 
but  too  likely  to  ensue.  The  degree  of  sight,  the  state  of  the  field  of 
vision,  and  the  tension  of  the  eyeball,  should  be  especially  watched. 
If  in  such  a  case  the  lens  swells  up  very  considerably,  it  may  be  wise  to 
perform  linear  or  scoop  extraction  combined  with  a  large  iridectomy, 
in  the  hope  that  the  absence  of  the  lens  may  diminish  the  inflammation, 
although  it  must  be  remembered  that  the  chief  exciting  cause — the 
foreign  body — still  remains  beliind,  and  may  at  any  time,  even  after 
the  lapse  of  years,  again  set  up  inflammation.  In  all  such  cases  of 
injury,  the  condition  of  the  other  eye  must  also  be  anxiously  watched. 
At  the  earliest  symptoms  of  sympathetic  inflammation,  or  even  of  well- 
marked  and  recurrent  sympathetic  irritation,  the  wounded  eye  should 
be  at  once  removed,  for  only  thus  can  we  ensure  the  safety  of  the  other. 
If  the  injury  is  so  severe  that  the  sight  is  greatly,  and  probably  per- 
manently, impaired,  the  immediate  removal  of  the  eye  may  be  indicated, 
even  although  the  other  eye  does  not  sympathise.  This  is  especially  the 
case  amongst  the  labouring  classes,  who  cannot  be  under  our  immediate 
supervision,  or  cannot  afford  the  time  to  undergo  a  lengthened  course 
of  treatment  without  the  hopes  of  regaining  any  useful  degree  of 
vision.  The  same  course  may  be  advisable  amongst  the  higher  classes, 
if  from  circumstances — such  as  officers  being  ordered  abroad,  necessity 
for  a  long  voyage,  etc. — they  cannot  be  under  constant  supervision,  so 
that  the  earliest  symptoms  of  symjoathetic  inflammation  may  be  detected. 

13.— REMOVAL  OF  SOFT  CATARACT  BY  A  SUCTION 
INSTRUMENT. 

In  the  extraction  of  soft  cataract  through  a  simple  linear  incision, 
some  difficulty  is  occasionally  experienced  in  removing  the  fii'mer 
portions  without  exerting  a  certain  amount  of  pressure  upon  the  globe, 


272 


DISEASES  OF   THE  CRYSTALLINE  LENS. 


Fig.  44. 


or  introducing  the  curette  into  the  anterior  chamber.  This  difficulty 
has  led  Mr.  Pridgin  Teale*  to  the  ingenious  employment  of  a  suction 
curette  for  the  more  easy  and  complete  extraction  of  soft  cataract. 

His  instrum.ent  consists  of  three  parts — a  curette,  a  handle,  and  a 
suction-tube. 

"  The  curette  is  the  size  of  the  ordinary 
curette,  but  differs  from  it  in  being  roofed 
in  to  within  one  line  of  its  extremity,  thus 
forming  a  iuhe  flattened  on  its  upper  sur- 
face, and  terminating,  as  it  were,  in  a  small 
cup.  The  curette  is  screwed  into  the 
'  handle.' 

"  The  handle  receives  the  curette,  and  is 
hollow  for  a  short  distance,  thus  being  a 
continuation  of  the  tube  of  the  curette. 
Passing  out  at  right  angles  from  this  por- 
tion of  the  handle  is  a  further  continuation 
of  the  tube,  to  which  the  '  suction-tube ' 
can  be  fixed. 

"  The  sudion-tiibe  is  a  piece  of  india- 
rubber  tubing,  ten  or  twelve  inches  long, 
having  an  ivory  or  metal  mouth-piece  at  one 
end,  and  fitting  on  to  the  projecting  part  of 
the  handle  by  the  other." 

Mr.  Teale  describes  his  mode  of  using 
it  thus  : — "  The  anterior  capsule  of  the  lens 
having  been  freely  torn  asunder  by  two 
needles,  a  small  opening  was  made  in  the 
cornea  by  the  broad  needle,  through  which 
the  suction  curette  was  introduced.  Holding 
the  open  end  of  the  curette  in  the  area  of 
the  pupil,  and  slightly  depressing  it  towards 
the  posterior  capsule,  I  withdrew,  by  suc- 
tion, the  soft  matter,  the  pupil  becoming 
perfectly  clear  in  a  few  seconds." 

Mr.  Bowman  has  devised  an  excellent 
suction  syringe  (Fig.  44),  the  use  of  which 
is,  I  think,  more  easy,  and  can  be  regulated 
with  more  nicety  than  the  curette.f  The 
operator  having  made  an  incision  in  the 
cornea  with  the  broad  needle,  and  freely 
After  l;:i\vs()n.  divided  thclcns,  can  introduce  the  nozzle  of 

*  "  R.  L.  O.  H.  Rep.,"  iv,  2,  197. 

+  Both  Mr.  Tcale's  and  Mr.  Bowman's  instrumcnls  arc  made  by  Messrs.  Weiss. 


SPERINO'S   TREATMENT   OF   CATARACT   BY   PARACENTESIS.    273 

the  instnament  (which  is  to  be  held  in  the  right  hand)  in  the  corneal 
apertm-e,  and  gently  "  suck  out  "  the  soft  lens  substance. 

Although  it  appears  that  the  idea  of  employing  suction  for  the 
removal  of  cataract  dates  back  as  far  as  the  fourth  century,  and  that  it 
has  since  been  advocated  by  several  authors,  more  especially  in  later 
years,  by  Blanchet  and  Langier,  it  never  attained  a  recognised  position 
until  it  was  introduced  by  Mr.  Teale.  This  operation  has  now  met 
with  much  and  deserved  favour,  more  especially  at  the  Royal  London 
Ophthalmic  Hospital,  Moorfields,  where  it  has  been  employed  with 
marked  success.  It  is  especially  indicated  in  soft  cortical  cataract, 
which  may  generally  be  very  readily  and  completely  removed  by  the 
suction  instrument.  If  the  cataract  be  somewhat  more  firm  in  con- 
sistence, it  will  be  well  to  break  it  up  with  the  needle  a  few  days 
previously.  I  have  also  used  it  with  much  advantage  in  removing 
portions  of  soft  cortical  substance  which  have  remained  behind  in  the 
pupil  in  the  operations  for  senile  cataract,  either  in  the  common  flap  or 
Von  Graefe's  operation,  for  such  portions  may  often  be  more  readilj 
and  thoroughly  removed  in  this  way  than  by  rubbing  the  eyeball  or  the 
re-introduction  of  the  scoop.  Some  care  and  delicacy  are,  however, 
required  in  the  use  of  this  instrument,  for,  if  too  great  a  suction  power 
is  employed,  hypersemia  {ex  vacuo')  of  the  iris  and  the  deeper  tunics  of 
the  eyeball  may  easily  be  produced. 

14.— SPERINO'S  TREATMENT  OF  CATARACT  BY 
PARACENTESIS.* 

This  mode  of  treatment  is  chiefly  based  upon  the  theory  that  the 
impairment  of  vision  in  cataract  is  partly  dependent  upon  a  temporary 
disturbance  in  the  intra-ocular  circulation,  especially  an  occasional  state 
of  congestion  of  the  choroid,  and  partly  upon  the  opacity  of  the  lens. 
Dr.  Sperino  holds  that  the  opaque  lens  fibres  may  regain  their  trans- 
parency as  long  as  their  intimate  structure  is  not  disorganised,  which 
always  follows,  more  or  less  rapidly,  upon  the  opacity,  but  less  so 
in  old  than  in  young  persons.  Now,  as  the  operation  of  tapping  the 
anterior  chamber  relieves  the  intra-ocular  circulation,  it  often  produces 
a  marked  and  immediate  improvement  in  the  sight,  and  in  some  cases 
often- repeated  tappings  have  at  last  efiected  a  complete  cure.  In  others 
their  efi'ect  has  been  but  moderate,  or  even  negative.  The  operation 
consists  in  making  a  small  puncture  with  a  broad  needle  at  the  edge  of 
the  cornea  or  slightly  in  the  sclerotic ;  a  blunt  probe  is  then  inserted 
between  the  lips  of  the  wound,  and  the  aqueous  humour  slowly 
evacuated.       The    evacuations   by   the    same  opening    may  be   made 

*  Vide  a  most  interesting  work  by  Dr.  Sperino,  entitled  "  Etudes  Cliniques  sur 
I'Evacuation  repetee  de  I'lluraeur  aqueuse  dans  les  Maladies  de  I'CEil,"  Tiu'in,  1862. 
Also  a  review  of  this  work  in  the  "  Ophthalmic  Review,"  vii,  p.  294. 

T 


274  DISEASES   OF   THE  CRYSTALLIXE  LENS. 

repeatedly  during  a  single  sitting,  followed  by  an  interval  of  several 
days,  or  singly  at  an  interval  of  a  day  or  two.  The  operations  in 
cataract  were  repeated  a  great  number  of  times.  In  one  case  167 
■tappings  were  made,  and  finally  linear  extraction  was  performed.  I 
am  not  aware  that  this  treatment  has  been  adopted  by  any  other  surgeon 
on  a  sufficiently  large  scale  to  warrant  any  exact  conclusion  as  to  its 
efficacy.  It  would  be,  I  think,  very  difficult  to  find  patients  who  would 
submit  to  such  a  very  protracted  course  of  treatment  and  such  numerous 
operations. 

15.— OPERATIONS  FOR  CAPSULAR  AND  SECONDARY 
CATARACT. 

I  have  already  stated  that  capsular  cataract  often  occurs  in  retro- 
gTCssive  lenticular  cataract,  and  that  in  such  cases  it  may  be  advisable 
to  remove  the  lens  in  its  capsule.  If,  in  an  operation  for  senile  cataract, 
the  capsule  is  found  so  tough  and  thickened  that  it  resists  the  pricker, 
it  should  be  torn  across  with  a  sharp  hook,  and  then,  after  the  extraction 
of  the  lens,  the  capsule  should  be  removed  by  the  hook  or  a  pair  of 
forceps.  In  such  cases  the  connexion  between  the  posterior  capsule  and 
the  hyaloid  is  not  unfrequently  loosened,  and  the  lens  may  often  be 
readily  extracted  in  its  capsule  by  the  hook.  Some  operators,  in  making 
the  section,  divide  the  tough  capsule  across  with  the  point  of  the  knife. 
Secondary  cataracts  vary  much  in  thickness  and  opacity.  They 
may  be  produced  by  portions  of  lens  substance  remaining  behind  and 
becoming  entangled  in  the  capsule,  by  the  deposition  of  lymph  upon  the 
latter,  or  by  the  proliferation  of  the  intra-capsular  cells. 

Again,  if  the  more  fluid  constituents  of  a  cataract  become  absorbed 
and  the  cortical  substance  undergoes  chalky  or  fatty  degeneration,  the 
lens  gradually  dwindles  down,  and  assumes  the  appearance  of  a  flattened, 
shrivelled  disc. 

Mr.  Bowman*  has  also  called  special  attention  to  another  form  of 
secondary  cataract,  in  which  the  capsule,  though  quite  transparent,  is 
crumpled  or  wi'inkled,  and  thus  produces  much  confusion  of  vision  by 
irregularly  refracting  the  rays  of  light.  This  condition  of  the  capsule 
may  easily  escape  detection,  even  althougli  the  eye  be  examined  with 
the  oblique  illumination,  and  is  not  perhaps  noticed  until  the  ophthal- 
moscope is  employed,  when  the  observer  finds  that  he  cannot  obtain  a 
clear  and  distinct  view  of  the  optic  disc,  but  that  it  looks  somewhat  dis- 
torted. On  then  getting  the  capsule  itself  into  focus,  the  wrinkles  may 
be  readily  observed. 

No  operation  for  secondary  cataract  should  be  performed  until  the 
eye  has  quite  recovered  from  the  cataract  operation  and  is  entirely  free 

*  "  R.  L.  0.  11.  Ecp.,"  iv. 


OPERATIONS   FOR   CAPSULAR   AND   SECONDARY   CATARACT.   275 

from  all  in-itation.  Generally  three  to  four  months  should  be  allowed  to 
elapse  between  the  two  operations.  Nor  should  it  be  done  if  the  area 
of  the  pupil  is  not  of  a  good  size.  If  it  has  become  contracted,  or  is 
partially  occupied  by  lymph,  or  if  there  are  extensive  posterior  synechia), 
a  preliminary  iridectomy  should  be  made,  and  then,  when  the  eye  has 
become  quiescent,  the  operation  upon  the  capsule  may  be  performed. 

Formerly,  the  favourite  mode  of  operating  was  by  the  removal  of  the 
obstructing  membi-ane.  But  this  is  .falling  more  and  more  into  disuse, 
as  it  often  proves  a  very  dangerous  operation  and  is  far  less  safe  than 
opening  up  the  membrane  by  the  needle,  which  is  attended  by  much  less 
risk  of  setting  up  inflammation.  Moreover,  it  is  a  well-established  fact 
that  a  small  clear  aperture  in  the  opaque  membrane  will  afibrd  most 
excellent  sight. 

For  the  needle  operation  chloroform  is  hardly  necessary,  unless  the 
patient  proves  very  unmanageable.  The  eyelids  should  be  kept  apart 
Avith  the  stop  speculum,  and  the  eye  may  be  steadied  with  the  forceps. 
Bowman's  fine  stop  needle  should  then  be  passed  tkrough  the  cornea  at 
a  short  distance  from  the  margin,  and  the  operator  should  endeavour  to 
tear  a  hole  in  the  centre  of  the  opaque  membrane.  The  portion  which 
is  thinnest,  least  opaque,  and  consists  chiefly  of  wrinkled  capsule,  should 
be  selected  for  this  purpose.  It  is  to  be  torn  across  in  difierent  direc- 
tions, the  point  of  the  needle  comminuting  the  membrane,  without, 
however,  being  allowed  to  go  deeply  into  the  vitreous  humour.  If  the 
operator  finds,  after  one  or  two  inefiectual  attempts  to  transfix  it  and 
tear  it  through,  that  the  false  membrane  yields  before  the  needle  and 
eludes  it,  or  if  it  is  too  tough  and  firm  to  be  torn  through,  he  should  at 
once  have  recourse  to  a  second  needle.  This  is  to  be  passed  into  the 
anterior  chamber  from  an  opposite  point  of  the  cornea.  Transfixing  and 
steadying  the  false  membrane  with  the  needle  held  in  his  left  hand,  the 
operator  employs  the  other  needle  to  tear  the  membrane  and  open  it  up. 
Or  the  points  of  the  needles  may  be  made  to  cross  each  other,  and  then, 
after  being  revolved  a  few  times  round  each  other,  be  separated,  which 
will  cause  the  membrane  to  be  torn  across.  Great  care  must  be  taken 
to  use  the  needles  with  extreme  delicacy,  and  not  to  di'ag  rouglily  upon 
the  adhesions  between  the  capsule  and  the  iris,  otherwise  severe  inflam- 
mation may  be  set  up.  If  any  portion  of  the  iris  should  have  been  con- 
siderably dragged  upon  during  the  use  of  the  needles,  it  may  be  advisable 
to  excise  this  segment,  in  order  to  allay  any  tendency  to  inflammatory 
reaction.  This  ingenious  double-needle  operation  was  first  devised  by 
Mr.  Bowman,*  and  has  proved  a  most  valuable  addition  to  Ophthalmic 
Surgery. 

Should  the  false  membrane  be  found  but  slightly  adherent  to  the 

*  "  Med.  Cliii-.  Traus.,"  1853,  p.  315. 

T    2 


276 


DISEASES   OF   THE   CRYSTALLINE   LENS. 


iris,  so  that  it  floats  almost  freely  in  the  pupil,  the  adhesions  may  be  torn 
through  by  the  needle,  and  the  whole  membrane  extracted  by  the  canula 
or  small  iris  forceps  through  a  linear  incision.  If  the  adhesions  are 
found  to  be  so  firm  that  a  good  deal  of  force  would  have  to  be  employed 
to  break  them  down  or  to  divide  them,  this  should  on  no  account  be 
attempted  ;  but  the  free  portion  should  be  caught  by  a  sharp  hook,  gently 
drawn  thi'ough  the  linear  incision,  and  snipped  off,  which  will  leave  a 
good-sized  opening  in  the  capsule. 

In  cases  of  chalky  or  siliculose  cata- 
Fig.  45.  ract,  in  which  the  capsule  looks  like  a 

little  wrinkled  bag  containing  small 
chalky  chips  of  lens,  it  may  be  possible 
to  remove  the  whole  capsule  with  a 
sharp  hook  through  a  good- sized  linear 
incision,  as  in  Fig.  45.  But  it  is  often 
a  very  dangerous  operation,  setting  up 
perhaps  severe  irido-choroiditis,  which 
may  even  lead  to  atrophy  of  the  eyeball. 
After  an  operation  for  secondary 
cataract,  atropine  should  be  applied, 
the  patient  be  kept  in  a  somewhat 
darkened  room  for  a  few  days,  and 
After  Stellwag.  carefully  watched,    in    order  that  the 

first  symptoms  of  inflammatory  reac- 
tion, accompanied,  perhaps,  by  increased  intra-ocular  tension,  may  be 
detected.  Within  from  twelve  to  twenty-four  hours  of  the  operation 
the  patient  may  experience  a  good  deal  of  pain  in  and  around  the  eye, 
and  down  the  corresponding  side  of  the  nose  (ciliary  neuralgia)  ;  there  is 
perhaps  some  subconjunctival  injection  and  lachrymation,  and  the  sight 
appears  somewhat  cloudy.  On  trying  the  tension  of  the  eyeball  it  is 
found  increased,  and  the  iris  pushed  forward  (sometimes  partially),  so 
that  the  anterior  chamber  is  narrowed.  If  the  intra-ocular  tension  is 
considerably  increased  (T  2),  and  this  persists  for  twelve  hours  from  the 
commencement,  Mr.  Bowman*  strongly  advises  that  the  bulging  part 
of  the  iris  should  be  punctured  with  a  broad  needle,  thus  establishing  a 
communication  between  the  anterior  and  posterior  chambers,  which  will 
generally  diminish  the  intra-ocular  pressure  and  cut  short  the  inflam- 
mation. 

Dr.  AgneWjt  of  New  York,  has  devised  the  following  operation.  He 
passes  a  stop  needle  through  the  centre  of  the  membrane,  thus  fixing 
both  the  eye  and  the  latter ;  he  then  makes  a  linear  incision  on  the  tem- 
poral side  of  the  cornea,  through  which  he  passes  a  small  sharp-pointed 

*  E.  L.  O.  H.  Eep.,  iv.,  366. 
t  "  Kl.  Monatsb.,"  1865,  p.  389. 


DISLOCATION   OF   THE   LENS.  277 

hook,  the  point  of  which  is  passed  into  the  same  opening  in  the  mem- 
brane as  the  needle.  He  now  tears  the  membrane,  and  by  a  rotatory 
movement  of  the  hook  rolls  it  up  round  the  lattei',  and  then  either  draws 
.it  out  altogether,  or,  if  this  cannot  be  done,  he  tears  it  widely  open. 


IC— DISLOCATION  OF  THE  LENS  (ECTOPIA  LENTIS). 

The  dislocation  of  the  lens  may  either  be  partial  or  complete.  In  the 
latter  case  it  may  be  displaced  into  the  vitreous  or  aqueous  humours,  or 
beneath  the  conjunctiva. 

Partial  Dislocation. — In  the  slightest  degree  of  partial  displacement 
the  lens  is  simply  turned  somewhat  upon  its  axis,  one  portion  of  its 
periphery  being  tilted  obliquely  forwards  against  the  iris,  the  other 
backwards  and  away  from  the  latter.  Or  again,  the  dislocation  may  be 
eccentric,  the  lens  being  somewhat  shifted  towards  a  certain  direction, 
so  that  its  centre  no  longer  corresponds  to  the  optic  axis,  but  lies  more 
or  less  considerably  to  one  side  of  it ;  the  periphery  of  the  lens  may 
even  lie  across  the  normal  pupil.  This  form  of  displacement  generally 
occurs  in  a  downward  direction  ;  but  it  may  also  take  place  upwards 
and  inwards,  or  upwards  and  outwards.  Such  partial  displacement  of 
the  lens  may  be  occasioned  by  various  causes,  amongst  others  by  ante- 
rior synechia,  for  if  in  such  a  case  an  adhesion  exists  between  the  iris 
and  the  capsule  of  the  lens,  the  latter  is  drawm  forwards  with  the  iris  at 
this  point,  and  therefore  somewhat  displaced  or  tilted.  It  may  also 
occur,  as  Stellwag  has  pointed  out,  in  cases  of  anterior  scleral  staphy- 
loma. 

On  examining  an  eye  affected  with  partial  displacement  of  the  lens, 
we  find  that  when  it  is  moved  rapidly  about  in  diiferent  directions,  the 
iris  is  slightly  tremulous  at  the  point  where  it  has  lost  the  support  of  the 
lens,  where  the  latter  has  receded  from  it.  Moreover,  it  is  here  also 
somewhat  cupped  or  curved  back,  being  on  the  other  hand  pushed 
forward  and  prominent  at  the  point  where  the  edge  of  the  lens  is 
tilted  forward  against  it.  In  the  former  situation  the  anterior  chamber 
will  consequently  be  slightly  deepened,  in  the  latter  narrowed.  If  the 
pupil  is  widely  dilated  with  atropine,  we  can  easily  recognise  the 
altered  position  of  the  lens  by  the  aid  of  the  oblique  illumination, 
or  still  better,  by  the  direct  examination  with  the  ophthalmoscope. 
With  the  latter,  the  free  edge  of  the  lens  will  be  noticed  as  a  sharply 
defined,  dark,  curved  line,  traversing  the  red  fundus,  and  forming  the 
outline  of  a  transparent  or  opaque  lenticular  disc.  If  the  displacement 
is  so  great  that  a  considerable  portion  of  the  background  of  the  eye  can 
be  examined  through  that  part  of  the  pupil  in  which  the  lens  is  absent, 
a  distinct  erect  image  of  the  details  of  the  fundus  will  be  obtained.     In 


k 


278  DISEASES   OF   THE   CRYSTALLINE  LENS. 

tlie  reverse  image  the  prismatic  action  of  the  edge  of  the  lens  can  be 
easily  observed,  for  then  the  double  image  of  the  fundus  will  appear, 
and  the  two  images  cannot  be  simultaneously  distinctly  seen,  for  whilst 
the  one  is  clearly  defined,  the  other  will  appear  hazy,  and  in  order  to 
render  the  latter  distinct,  either  the  position  of  the  observer's  eye  or  of 
the  ocular  lens  must  be  changed.  Such  a  partial  displacement  of  the 
lens  will  also  have  a  peculiar  eifect  upon  the  patient's  sight,  for  he  will 
generally  be  affected  with  monocular  diplopia,  or  polyopia,  which  is  due 
to  the  difference  in  the  refraction  of  the  two  portions  of  the  pupil,  and 
to  the  prismatic  action  of  the  peripheral  portion  of  lens  which  lies  across 
it.  The  state  of  refraction  will  also  differ  in  the  two  portions  of  the 
pupil,  for  in  that  in  which  the  lens  is  absent  a  very  considerable  degree 
of  hypermetropia  will  exist.  Von  Graefe*  mentions  a  case  of  displace- 
ment of  the  lens,  in  which,  when  the  patient  was  endeavouring  to  dis- 
tinguish a  small  object,  the  eye  deviated  in  a  certain  direction,  in  order 
that  the  rays  might  impinge  upon  the  central  portion  of  the  lens.  If 
the  pupil  is  small,  the  patient  may  observe  the  edge  of  the  displaced 
lens  entopically,  or  the  same  phenomenon  may  be  produced  with  a  dilated 
pupil,  if  he  looks  through  a  minute  aperture  in  a  card  or  a  stenopaic 
apparatus. 

If  the  dislocation  of  the  lens  is  due  to  an  accident,  etc.,  e.g.,  a  severe 
blow  upon  the  eye,  the  sight  is  often  greatly  impaired  directly  after- 
wards by  haemorrhage  into  the  aqueous  and  vitreous  humours.  As  the 
blood  becomes  absorbed  the  sight  may  gradually  improve,  if  there  is  no 
other  deep-seated  lesion. 

17.— COMPLETE  DISLOCATION  OF  THE  LENS 

Into  the  Vitreo2is  Humour. — The  iris  will  be  observed  to  be  markedly 
tremulous  when  the  eye  is  moved  in  different  directions,  and  the 
anterior  chamber  will  be  somewhat  deepened.  If  the  catoptric  test  be 
employed,  it  will  be  found  that  the  lenticular  reflections  are  wanting. 
On  examining  the  eye  with  the  oblique  illumination,  the  absence  of  the 
reflection  from  the  anterior  capsule  will  also  be  noticed,  and  the  position 
of  the  displaced  lens  will  in  most  cases  be  easily  recognised,  more  espe- 
cially if  the  pupil  is  dilated,  as  a  portion  of  the  lens  generally  occupies 
some  part  of  the  pupil,  or  floats  across  it  when  the  eye  is  moved.  If 
the  lens  is  opaque,  the  sight  will  of  course  be  temporarily  lost  when  the 
lens  lies  across  the  pupil.  The  position  of  the  lens  will  vary  with  that 
of  the  head.  If  the  latter  is  held  erect,  it  will  sink  down  into  the 
vitreous  humour ;  if  the  head  is  bent  forward,  the  lens  will  fall  against 
the  pupil,  or  may  even  pass  through  it  into  the  anterior  chamber.    With 

*  "A.  f.  0.,"i,  2,  291. 


COMPLETE   DISLOCATION   OF   THE  LENS.  270 

the  ophthalmoscope,  the  situation  of  the  lens  in  the  vitreous  humour 
can  be  very  easily  ascertained,  for  it  will  appear  in  the  form  of  a  darkish 
lenticular  body,  generally  lying  in  the  lower  portion  of  the  vitreous 
humour.  The  latter  is  of  course  more  or  less  fluid,  generally  entirely 
so.  In  spontaneous  luxations,  the  lens  is  frequently  opaque,  and  in  such 
cases  the  sight  will  be  greatly  improved.  Even  if  it  is  transparent  at 
the  time  of  the  displacement,  it  generally  becomes  opaque  in  the  course 
of  a  few  months.  In  such  cases  the  cataract  may  assume  the  lamellar 
form,  only  some  layers  around  the  nucleus  becoming  clouded.  But  a 
dislocated  lens  may  retain  its  transparency  for  very  many  years,  if  its 
capsule  is  uninjured.  Mooren  has  seen  a  case  in  which  the  lens 
remained  clear  for  36  years.*  When  the  lens  has  sunk  into  the  vitreous 
humoui"  out  of  the  area  of  the  pupil,  the  eye  will  be  extremely  hyper- 
metropic, in  fact,  in  a  similar  condition  to  one  operated  on  for  cata- 
ract. 

Dislocation  of  the  Letis  into  the  Anterior  Chamber. — Although  this 
condition  may  occur  in  a  transparent  lens,  it  is  more  frequent  when  the 
latter  is  chalky,  and  perhaps  diminished  in  size.  The  displacement  is 
moreover  generally  spontaneous  and  gradual,  and  not  due  to  an  acci- 
dent. There  can  be  no  difficulty  in  recognising  the  affection,  for  in  the 
anterior  chamber  Avill  be  observed  a  lenticular  disc,  either  transparent 
and  diaphonous,  or  white  and  opaque. 

If  the  lens  is  in  its  capsule,  a  sharply  defined  yellow  border  will  be 
noticed,  encircling  the  disc  (Graefe).  The  lens  may  be  either  entirely 
in  the  anterior  chamber,  or  a  part  may  lie  in  and  behind  the  pupil. 
The  latter  condition  is  especially  dangerous,  as  the  presence  of  the 
lens  in  the  pupil  is  apt  to  set  up  irritation  and  inflammation  of  the 
iris,  from  maintaining  a  constant  "  teazing  "  and  contusion  of  the  edges 
of  the  pupil.  In  some  cases,  the  lens  does  not  retain  its  position  in 
the  anterior  chamber,  but  falls  back  again  into  the  vitreous  humour, 
and  it  may  thus  frequently  alternate  in  its  position,  being  sometimes 
found  in  the  anterior  chamber,  at  others  in  the  vitreous.  Its  presence 
in  the  anterior  chamber  will  cause  a  considerable  deepening  of  the 
latter,  and  a  cupping  back  of  the  iris.  Adhesions  are  sometimes  formed 
between  the  capsule  and  the  cornea ;  the  latter  may  ulcerate  and  the 
lens  escape  through  the  perforation  ( Graefe). f 

Severe  inflammatory  symptoms  may  also  supervene,  implicating 
the  cornea,  iris,  and  the  deeper  structures  of  the  eyeball,  and  accom- 
panied perhaps  by  an  increase  in  the  intra-ocular  tension.  There  is 
often  also  very  severe  periodic  ciliary  neuralgia.  But  the  inflamma- 
tion may  even  extend  sympathetically  to  the  other  eye.  On  the  other 
hand,  the  lens  may  remain  for  a  very  long  period  in  the  anterior 
chamber  without  producing  any  irritation  or  pain. 

*  Mooren,  257.  t  "  A.  f.  O.,"  i,  1,  343. 


280  DISEASES   OF   THE   CRYSTALLINE   LENS. 

Dislocation  of  the  Letts  binder  the  Conjunctiva. — This  is  always  due  to 
an  accident,  generally  to  a  heavy  blow  from  some  blunt  substance, 
hitting  the  eye  below,  and  knocking  it  forcibly  against  the  roof  or 
upper  edge  of  the  orbit,  hence  the  most  frequent  seat  of  this  displace- 
ment is  upwards  and  inwards,  or  upwards  and  outwards.  The  rupture 
in  the  choroid  generally  occurs  quite  anteriorly,  between  or  in  front  of 
the  insertion  of  the  recti  muscles.  This  form  of  dislocation  is  most 
frequently  met  with  in  persons  after  the  age  of  thirty  or  forty,  when 
the  sclerotic  has  lost  its  elasticity.  It  is  characterised  by  the  follow- 
ing appearances : — Beneath  the  conjunctiva  is  noticed  a  small,  well 
marked,  prominent  tumour,  which  may  even  cause  a  little  circum- 
scribed prominence  in  the  lid.  The  colour  of  the  tumour  varies,  it 
may  be  dark  from  the  presence  of  effused  blood  in  and  beneath  the 
conjunctiva,  or  of  a  portion  of  prolapsed  iris,  or  the  conjunctiva  may 
be  transparent,  and  only  slightly  injected,  and  then  the  greyish-white 
lens  can  be  easily  recognised.  But  in  some  cases  only  a  part  of  the 
lens  has  escaped  beneath  the  conjunctiva,  the  rest  remaining  within 
the  eye.  Whilst  the  sclerotic  has  been  ruptured,  the  conjunctiva  on 
account  of  its  laxity  and  elasticity  has  generally  yielded  before  the  lens, 
and  has  not  given  way  or  been  torn,  but  covers  the  displaced  lens.  The 
pupil  is  mostly  irregular  and  drawn  up,  and  there  is  a  more  or  less 
considerable  prolapse  of  the  iris.  If  the  capsule  has  been  ruptured,  and 
the  lens  escaped  from  it,  the  remains  of  the  torn  shreds  of  capsule 
will  be  seen  with  the  ophthalmoscope,  just  as  after  an  operation  for 
cataract. 

Dislocation  of  the  lens  may  be  spontaneous,  and  is  then  generally 
due  to  a  gradual  relaxation  or  elongation  of  the  suspensory  ligament, 
or  its  partial  rupture.  In  such  cases  the  lens  is  often  opaque,  and  the 
vitreous  humour  perhaps  fluid.  Moreover,  in  such  a  condition  a  very 
slight  shock  to  the  eye,  which  has  perhaps  been  unnoticed  by  the 
patient,  will  produce  dislocation  of  the  lens.  The  affection  may  also 
be  congenital,  and  even  hereditary,  occurring  in  several  members  of 
the  same  family.  Thus,  Mr.  Dixon*  mentions  a  case  in  which  a 
partial  displacement  of  the  lens  existed  in  a  mother  and  three  sons. 
Mr.  Bowman  narrates  a  case  in  which  a  patient  suffering  from  disloca- 
tion of  the  lens  had  two  uncles  affected  with  the  same  disease.  If  the 
affection  is  congenital,  it  is  generally  accompanied  by  more  or  less 
amblyopia,  and  perhaps  nystagmus,  and  such  eyes  are  as  a  rule  also 
very  myopic.  In  such  cases  the  dislocation  mostly  exists  in  both 
eyes.  But  the  most  frequent  cause  is  an  injury  to  the  eye  from  blows 
or  falls  upon  this  organ,  which  cause  a  rupture  of  the  suspensory 
ligament,  and  a  more  or  less  complete  dislocation  of  the  lens.  Mr. 
*  "  Roy.  Lond.  Ophtlial.  Hosp.  Reports,"  i,  55. 


COMPLETE   DISLOCATION   OF   THE   LENS.  281 

Bowman*  has  called  attention  to  the  fact,  that  glancomatous  symptoms 
occasionally  arise  in  cases  of  dislocation  of  the  lens.  This  appears  to 
be  due  to  the  pressure  of  the  lens  upon  the  iris,  thus  dragging  upon 
its  ciliary  attachment,  which  sets  up  irritation,  and  a  hypersecretion 
of  the  fluids  within  the  eye. 

The  treatment  of  dislocation  of  the  lens  must  vary  according  to 
the  exigencies  of  the  case.  Where  it  is  but  slight,  the  sight  may  not 
be  materially  affected,  and  no  operative  interference  may  be  indicated. 
If,  however,  the  displacement  is  so  considerable,  that  the  free  edge  of 
the  lens  lies  in  the  pupil,  and  thus  gives  rise  to  great  impairment  of 
the  sight,  and  very  annoying  diplopia,  an  endeavour  should  be  made 
to  remedy  this  defect.  The  best  mode  of  treatment  is  that  originally 
adopted  by  Wecker,t  viz.,  an  iridodesis  made  in  the  opposite  direction 
to  that  in  which  the  lens  is  displaced,  so  that  the  artificial  pupil  will 
be  brought  opposite  that  portion  of  the  eye  in  which  the  lens  is  de- 
ficient, and  the  iris  will  be  drawn  over  the  displaced  lens,  and  cover 
the  latter  to  a  more  or  less  considerable  extent.  The  patient  will  then 
be  in  the  condition  of  a  person  whose  lens  has  been  extracted,  and  he 
will  be  able  to  see  well  both  at  a  distance  and  near  at  hand  through 
suitable  convex  glasses.  Iridodesis  is  in  such  cases  for  obvious  reasons 
to  be  preferred  to  an  iridectomy.  If  the  lens  is  completely  dislocated 
into  the  vitreous  humour,  and  is  setting  up  no  disturbance,  it  is  wiser 
not  to  interfere.  But  if  inflammatory  complications  arise,  or  the  sight 
is  much  impaired  by  the  lens  floating  about  across  the  pupil  when  the 
eye  is  moved,  it  will  be  best  to  remove  it.  An  iridectomy  should  be 
made  opposite  the  point  towards  which  the  lens  is  displaced,  and  the 
latter  is  then  to  be  removed  by  Critchett's  scoop.  The  operation  is, 
however,  often  very  dangerous,  for  a  considerable  amount  of  fluid 
vitreous  will  be  lost,  and  severe  irido-choroiditis  with  subsequent 
atrophy  of  the  globe  may  supei'vene. 

When  the  lens  is  luxated  into  the  anterior  chamber,  we  must 
endeavour  to  obtain  its  re-position  into  the  vitreous  humour,  by 
making  the  patient  assume  the  horizontal  posture,  and  applying  a 
compress  bandage.  If  it  falls  back  into  the  vitreous  humour,  its  main- 
tenance in  this  situation  may  be  assisted  by  an  iridodesis,  or  temporarily 
by  the  application  of  the  solution  of  Calabar  bean.  If  the  presence  of 
the  lens  in  the  anterior  chamber  sets  up  inflammatory  reaction,  or 
impairs  the  sight,  it  should  be  extracted  with  the  scoop,  and  it  will  be 
better  to  combine  an  iridectomy  with  this  operation.  The  incision 
should  be  made  in  the  lower  part  of  the  cornea  with  Graefe's  cataract 
knife.  To  prevent  the  escape  of  the  lens  into  the  vitreous  humour, 
Wecker  advises  that  it  should  be  transfixed  with  a  needle,  and  kept  in 

*  "  Roy.  Lond.  Oplith.  Hosp.  Reports,"  v,  1. 
t  Tide  Wecker,  2nd  edition,  p.  477. 


282  DISEASES  OF   THE   CRYSTALLINE  LENS. 

its  position  in  the  anterior  chamber,  until  the  scoop  can  be  introduced 
beneath  it.  If  the  lens  simply  disturbs  the  sight  without  setting  up 
any  inflammation,  we  may  endeavour  to  gain  its  absorption  by  the 
operation  of  division,  care  being  taken  not  to  lacerate  the  capsule  too 
freely,  but  rather  to  repeat  the  operation  several  times. 

In  the  subconjunctival  dislocation,  an  incision  should  be  made, 
and  the  lens  removed ;  and  the  prolapsed  portion  excised,  so  that  the 
wound  may  be  quite  smooth.  If  a  tolerably  firm  union  of  the  lips  of 
the  wound  has  already  taken  place,  it  will  suffice  to  apply  a  compress 
bandage  ;  but  if  the  rupture  in  the  sclerotic  is  gaping,  it  will  be 
better  to  unite  its  edges  with  one  or  two  fine  sutures,  in  the  same 
manner  as  has  been  advised  for  incised  wounds  in  this  region. 


Chapter  VI. 
THE    USE    OF    THE    OPHTHALMOSCOPE. 


It  was  formerly  supposed  that  the  black  appearance  of  the  pupil  is  due 
to  the  fact  that  all  the  light  which  enters  the  eye  is  absorbed  by  the 
choroid,  and  consequently  that  none  is  reflected  towards  the  observer. 
This,  however,  is  not  the  case,  for  a  considerable  portion  is  diffusely 
reflected,  and  may  be  caught  up  by  the  observer's  eye  if  this  is  placed 
in  the  direction  of  the  emerging  rays.  In  such  a  case,  the  pupd  no 
longer  appears  black,  but  is  luminous,  having  a  bright  red  glow. 
Gumming,  in  1846,  pomtedout  that  all  normal  eyes  are  luminous,  more 
especially  if  the  pupil  is  dilated ;  but  that  it  is  necessary,  in  order  to 
obtain  this  luminosity,  that  the  eye  of  the  observer  should  be  placed 
parallel  to  the  incident  rays,  that  is,  as  nearly  as  possible  in  the  direct 
line  between  the  source  of  light  and  the  eye  observed.  But  in  the  ordi- 
nary mode  of  examination  this  is  next  to  impossible,  as  the  observer's 
head  must  be  placed  between  the  light  and  the  patient's  eye,  and  will 
therefore  cut  ofi"  the  rays  passing  to  the  latter.  Moreover,  even  if  some 
of  the  reflected  rays  could  be  caught  up,  they  would  only  afibrd  the 
appearance  of  a  bright  red  glow,  or,  at  the  best,  but  a  very  confused 
and  indistinct  image  of  the  fundus,  owing  to  the  insuflSciency  of  the 
illumination  and  to  the  direction  of  the  emerging  rays.  For,  in  con- 
sequence of  the  optical  condition  of  the  eye,  the  incident  rays,  if  the  eye 
is  accommodated  for  the  object,  are  so  reflected  that  they  emerge  again 
in  exactly  the  same  direction  as  they  entered,  and  would  therefore  be 
brought  to  a  focus  at  the  point  whence  they  originally  emanated,  that 
is  at  the  source  of  light.  The  object  and  its  retinal  image  are,  in  fact, 
in  the  position  of  conjugate  foci.  The  pupil  of  the  patient's  eye  will 
therefore  appear  black  if  it  is  accommodated  for  the  pupil  of  the 
observer,  as  the  latter  will  then  only  see  the  reflection  of  his  o-v\ti 
pupil. 

A  glance  at  Fig.  46  will  readily  explain  this.  If  F  is  the  object, 
and  c  its  image  formed  upon  the  retina,  rays  reflected  from  c  will  be 
brought  to  a  focus  at  F,  so  that  whichever  of  these  two  points  is  the 
radiant- point,  the  other  will  be  the  focal  point.     Now,  if  we  place  our 


284  THE  USE   OF   THE   OPHTHALMOSCOPE. 

eye  at  F,  the  luminous  rays  emanating  from  our  pupil  (which  is 
black)  will  be  insuflacient  to  illumine  the  fundus  of  the  patient,  and 
hence  his  pupil  will  also  appear  black. 

Fig.  46. 
b' 


But,  in  certain  conditions  of  the  eye,  a  considerable  amount  of 
reflection  may  be  obtained,  as,  for  instance,  in  the  eyes  of  albinos, 
and  in  cases  in  which  the  retina  is  bulged  forwards  by  morbid  pro- 
ducts. It  is  a  well  known  fact  that  the  pupil  of  the  albino  is  markedly 
luminous.  This  is  not  caused,  as  is  often  supposed,  by  a  greater 
reflection  of  the  rays  which  enter  the  pupil,  on  account  of  the  defi- 
ciency of  the  pigment  in  the  choroid,  but  is  due  to  the  great  amount 
of  light  which  passes  through  the  iris  and  sclerotic.  The  truth  of 
this  statement  was  proved  by  Bonders,  who  placed  before  an  albinotic 
eye  a  small  screen,  having  a  circular  aperture  for  the  pupil,  but  cover- 
ing the  iris  and  sclerotic  in  such  a  manner  that  no  light  could  pass 
through  them.  It  was  then  found  that  the  pupil  lost  its  luminosity, 
and  at  once  acquired  the  usual  darkness  of  other  eyes. 

Again,  if  the  position  of  the  retina  is  altered,  it  being  bulged  forward 
by  a  tumour  behind  it  (amaurotic  cat's  eye)  or  by  fluid,  more  light 
will  be  reflected,  and  the  fundus  will  appear  luminous.  Moreover, 
on  account  of  the  more  anterior  position  of  the  retina,  the  emerging 
rays  will  be  divergent,  and  hence  easily  brought  to  a  focus  upon  the 
retina  of  the  observer. 

Briicke,  in  1844-47,  made  a  series  of  interesting  experiments  with 
regard  to  the  luminosity  of  the  eye,  and  showed  that  if  the  eye  under 
examination  is  neither  accommodated  for  the  light  nor  for  the  pupil  of 
the  observer,  but  for  some  other  nearer  point,  a  portion  of  the  light 
reflected  from  its  background  may  be  caught  up  by  the  observer,  and 
the  pupil  will  then  appear  red  and  luminous.  This  is  shown  in  the 
preceding  figure  (Fig.  46).  If  F  is  a  luminous  point  for  which  the 
eye  under  observation  (B)  is  accommodated,  the  rays  emanating  from 
F  will  be  brought  to  a  focus  upon  the  retina  at  c,  at  which  point  a  clear 
and  distinct  image  of  F  will  be  formed.  This  being  so,  the  rays 
reflected  from  c  will  unite  at  F,  for  F  and  c  are  conjugate  foci.  If  the 
eye  of  the  observer  (A)  be  placed  beside  F,  it  will  receive  no  luminous 


THE   USE   OF   THE   OPHTHALMOSCOPE.  285 

rays  from  B,  and  will  hence  see  the  pnpil  of  the  latter  black.  Now,  if 
whilst  the  eye,  B,  remains  accommodated  for  the  luminous  point,  F, 
the  latter  is  brought  nearer  to  the  eye,  to  F',  the  rays  emanating  from 
it  will  no  longer  be  brought  to  a  focus  on  the  retina  at  c,  but  behind 
it,  at  d,  and  a  circle  of  diffusion,  a  h,  will  be  formed  upon  the  retina. 
As  the  eye  is  accommodated  for  the  distance,  F,  the  rays  emanating 
from  the  points  of  the  circle  of  diffusion,  a,  b,  will  be  brought  to  a 
focus  at  a'  b',  and  there  form  an  enlarged  and  inverted  image  of  a  b. 
Hence  the  eye  of  the  observer,  placed  at  A,  will  receive  a  portion  of 
this  reflected  light,  and  therefore  the  pupil  of  B  will  appear  more  or 
less  luminous. 

We  shall  see,  hereafter,  that  Helmholtz  turned  this  experience  of 
Briicke's  to  a  practical  use,  and  constructed  his  simplest  ophthalmoscope 
upon  this  principle.  Before  entering  upon  this,  I  must  state  that 
Helmholtz,  in  1851,  devised  an  apparatus  by  which  the  observer 
was  enabled  to  place  his  eye  in  the  dii'ect  line  of  the  emerging  rays, 
and  thus  gain  a  view  of  the  fundus.  The  accompanying  figure  and 
description  of  this  instrument  are  from  Mr.  Carter's  admirable  transla- 
tion of  Zander's  work  on  the  ophthalmoscope — a  work  I  cannot  too 
warmly  recommend  to  all  who  wish  to  gain  a  thorough  knowledge  of 
the  theory  of  the  ophthalmoscope,  its  use  in  practice,  and  the  different 
morbid  changes  of  the  fundus  which  may  be  recognised  with  it.  The 
student  will  also  derive  great  benefit  from  the  perusal  of  Mr.  Hulke's 
and  Mr.  Wilson's  excellent  works  on  the  ophthalmoscope,  which, 
though  shorter  and  less  exhaustive,  yet  contain  a  great  amount  of 
information,  conveyed  in  a  very  clear  and  concise  manner. 

"  Under  certain  conditions,  however,  we  may  see  the  fundus  of  the 
human  eye  shine  with  a  reddish  lustre.  Such  conditions  are  shown  in 
Fig.  47,  where  jP  is  a  luminous  point,  and  S  a  polished  plate  of  glass, 
which  reflects  the  light  a  b  falling  upon  it,  into  the  observed  eye  B, 
in  a  direction  as  if  it  came  from  a  point  F'  lying  as  far  behind  the  plate 
S  as  the  actual  point  F  lies  before  it.  Disregarding  the  loss  of  light 
caused  by  irregular  reflection  and  other  circumstances,  the  rays  a  d 
and  b  c,  reflected  from  8  enter  the  observed  eye,  and  become  united  at 
e.  The  emerging  rays  in  their  exit  from  B  must  take  precisely  the 
same  course  as  in  their  entrance ;  they  proceed,  therefore,  in  the  con- 
verging cone  cb  a  d  to  the  plate  of  glass,  by  which  they  are  partly 
reflected  back  to  F,  while  the  remainder  proceed  in  an  unaltered  direc- 
tion forwards,  to  unite  in  a  focus  at  F'  and  then  again  to  become 
divergent.  If  now  the  eye  of  the  observer  be  placed  so  as  to  intercept 
them  before  their  union,  as  at  A'  it  receives  from  e  convergent  rays 
that,  made  more  convergent  by  its  own  refraction,  are  united  before 
they  reach  its  retina,  upon  which,  after  crossing,  they  form  only  the 
dispersion  circle  a  l3'.     The  eye  of  A'  would  certainly,  therefore,  receive 


I 


286 


THE   USE   OF   THE   OPHTHALMOSCOPE. 


no  image,  but  only  tlie  sensation  of  light— it  would  see  the  eye  B  illu- 
minated, and  the  same  wonld  happen  if  it  were  so  placed  as  to  intercept 
the  diverging  rays  behind  the  point  F'. 

Fig.  47. 


After  Zander. 


THE   USE   OF   THE   OPHTHALMOSCOPE.  287 

"  Affcci'  this  principle  was  annotincod  by  Von  Et'lach,  Professor 
H.  Helmlioltz,  then  of  Konigsbcrg,  and  since  of  Heidelberg,  was  the 
first  to  discover  the  reason  why  the  retina  was  not  distinctly  seen,  and 
to  find  the  means  of  rendering  it  visible.  The  problem  was  threefold  : 
the  observed  eye  must  be  snfficiently  illuminated ;  the  eye  of  the 
observer  must  be  placed  in  the  direction  of  the  emerging  rays,  and  these 
must  themselves  be  changed  from  their  convergence,  and  rendered 
divergent  or  parallel.  The  solution  of  the  main  difficulty  was  obtained 
when,  in  a  darkened  chamber,  the  light  of  a  lamp  was  allowed  to  fall  on 
a  well  polished  plate  of  glass  in  such  a  manner  that  the  rays  reflected 
thereffom  entered  the  eye  to  be  observed.  The  observer  placed  himself 
on  the  other  side  of  the  glass  plate,  and  made  the  convergent  rays 
divergent  by  a  concavelens.  Thus  in  Fig.  47  we  place  the  concave 
glass  c  before  the  eye  of  the  observer  A,  and  convert  the  convergent 
pencil  b  g  f  a,  coming  through  S,  into  the  divergent  pencil  g  i  h  /,  so 
that  the  eye  A  may  form  upon  its  retina  e  a  clear  image  of  the 
point  e. 

"  The  combination  of  such  an  illuminating  apparatus  with  suitable 
lenses  forms  an  instrument  by  which  it  is  possible  clearly  to  see  and 
examine  the  details  of  the  background  of  the  eye  of  another  person. 
To  this  instrument  Helmholtz  gave  the  name  of  Eye-mirror,  or  Ophthal- 
moscope." 

In  order  to  obtain  a  better  illumination  Helmholtz  afterwards  em- 
ployed three  plates  of  glass  instead  of  a  single  slip.  A  still  greater 
advance  was  made  when  Helmholtz  utilized  Briicke's  experiment  above 
referred  to,  and  employed  a  strong  convex  lens,  held  before  the  patient's 
eye,  to  converge  the  rays  reflected  from  a  large  cii'cle  of  diffusion 
formed  upon  the  retina.  In  this  way  an  enlarged  and  inverted  image 
of  the  fundus  was  formed  between  the  lens  and  the  observer.  This 
constitutes  the  "  examination  of  the  actual  inverted  image." 

Helmholtz  placed  the  flame  of  a  candle  before  the  eye  under  observa- 
tion, and  a  screen  behind  the  flame,  so  that  the  observer's  eye  could  be 
brought  close  to  the  source  of  light,  and  thus  catch  the  rays  after  they 
had  been  united  by  the  convex  lens,  and  formed  an  image  of  the  fundus. 
This  point  of  union  lies  at  the  focal  distance  of  the  lens.  This  mode  of 
examination  was,  however,  troublesome  and  inconvenient,  and  hence 
Riiete  had  recourse  to  a  concave  mirror  having  a  central  aperture  for 
the  observer's  eye,  and  he  thus  still  more  increased  the  illuminating 
power.  Since  then  different  forms  of  miiTor  have  completely  super- 
seded the  plates  of  polished  glass. 

The  following  description  and  illustration  from  Zander  clearly 
explain  the  action  of  the  concave  mirror  in  the  inverted  examination, 
i.e.,  the  use  of  a  convex  lens  placed  a  short  distance  from  the  eye  under 
observation,  so  as  to  converge  the  rays  emanating  from  the  cii'cle  of 


288 


THE   USE   OF   THE   OPHTHALMOSCOPE. 


difFusion  formed  upon  its  retina.   *  The  patient  is  to  accommodate  for 
an  infinite  distance,  so  that  the  rays  issue  parallel  from  this  eye. 

"  Examination  of  the  actual  Inverted  Image. — In  Fig.  48  F  is  again 
the  flame,  S  the  mirror,  L  the  convex  lens,  and  B  the  eye  observed. 

The  rays  a  e  b  f,  proceeding  conver- 
gent from  the   m.irror  and  rendered 
more   convergent    by   their   passage 
through  the  lens,   strike  the  cornea 
of  I?  in  c  and  d.    Rendered  still  more 
convergent  by  the  dioptric  apparatus 
of  B,  they  intersect  at   some    point 
in  front   of  the  retina,   for   example 
at    0,    and   form   on   the   retina   the 
dispersion    circle  a   8.     On   account 
of    the   passive  state    of    accommo- 
dation   of    the    eye,  the   rays    pro- 
ceeding from  it  "will   follow   courses 
parallel  to  the  lines  of  direction  «  x 
and  (3  x,  and  after  their  refraction  by 
the  lens  L  will  unite  to  form  at  a  /3' 
an  actual  inverted  image  of  a  /3."* 
In  this  mode  of  examination  it  will 
be  observed  that  the  aerial  image  of 
the  fundus   is  situated   between  the 
observer  and   the  convex  lens,    and 
that  it  is  inverted  and  enlarged.     If 
we  desire  to  increase  the  size  of  the 
image,  a  somewhat  weaker  object  lens 
(85^  to  4"  fociis)  should  be  employed, 
for  as  this  renders  the  rays  less  con- 
verging the   image  will    be   propor- 
tionately enlarged,    but  will    at   the 
same  time  lie  somewhat  further  from 
the   eye ;    this    is,   however,    accom- 
panied by  the  disadvantage  that  the 
field  of  vision  is  much  diminished  in 
size.     Hence  the  best  plan  is  to  use 
first  a  lens  of  2  or  2^  inches  focus, 
so  as  to  gain   a  view  of  the  whole  fundus,  and  then  to  change  this  for 
a  weaker  lens   if  we   desire  to  examine  any  special  part  of  the  back 
ground  with  particular  care  and  minuteness.     The  size  of  the  image 
may  also  be  considerably  magnified  by  placing  a  convex  lens  of  8  or 


*  Carter's  Trauslatiou  of  Zander,  p.  20. 


THE  USE   OF   THE   OPHTHALMOSCOPE. 


289 


10  inches  focus  in  the  little  clip  behind  the  mirror.     In  this  case  the 
observer  must,  however,  approach  somewhat  closer  to  the  patient. 

"  In  the  examination  of  the  virtual  erect  image  the  mirror  alone  is  used, 
without  the  aid  of  an  object 


lens,  the  observer  approach- 
ing very  closely  to  the  pa- 
tient's eye.  He  will  thus 
obtain  an  erect,  geometrical 
image  of  the  fundus,  the 
image  being  apparently  si- 
tuated behind  the  patient's 
eye,  as  in  Fig.  49.*  iJisthe 
examined  eye,  and  E'  the 
position  of  the  examiner's 
eye ;  r  r  are  divergent  rays 
from  F,  a  flame  incident  on 
the  concave  speculum  A  B, 
which  reflects  them  con- 
vergingly  as  r'  r'  to  E, 
about  two  inches  distant, 
upon  the  fundus  of  which 
they  form  the  cii'cle  of  dis- 
persion d  d.  The  rays  re- 
flected from  any  point  a  h 
within  the  circle,  after  leav- 
ing E,  assume  a  direction 
parallel  to  the  prolonga- 
tions of  the  lines  ache 
(which  pass  through  c  the 
optical  centre  of  E)  and 
reach  the  observer's  eye  at 
E',  on  the  retina  of  which 
they  form  an  inverted  image 
of  a  h,  wliich  is  mentally 
projected  as  the  enlarged, 
erect,  geometrical  image  a 
/3."  It  will  be  explained 
hereafter  that  it  is  gene- 
rally necessary  to  make  use 
of  an  ocular  lens  behind  the 
mirror,  in  order  to  gain  a 
clear  and  distinct  imajje  of 


Fig.  49. 


*  This   figui'e  and  its  explauatiou    arc  from  Mr.   nullce's    able    work   on   tlie 
Ophtbalmoscopc. 


290 


THE   USE   OF  THE   OPHTHALMOSCOPE. 


the  fundus.  The  nature  and  strength  of  this  lens  depend  upon  the 
state  of  refraction  of  the  eye  of  the  observer  and  that  of  the  patient's. 

I  must  now  pass  on  to  a  brief  description  of  the  different  forms  of 
ophthalmoscope  which  are  in  most  frequent  use.  For  a  full  and  accu- 
rate description  of  the  various  kinds  of  ophthalmoscope  which  have 
been  invented,  I  must  refer  the  reader  to  Mr.  Carter's  translation  of 
Zander. 

Ophthalmoscopes  may  be  divided  into  four  different  classes. 

1.  The  portable  or  hand  ophthalmoscopes.  Of  these  I  shall  notice 
those  of  Liebreich,  Coccius,  and  Zehender. 

2.  The  fixed  or  stand  ophthalmoscopes,  such  as  Liebreich's  and  its 
excellent  modification  by  Smith  and  Beck. 

3.  The  binocular  ophthalmoscopes  of  Giraud-Teulon,  and.  of  Laurence 
and  Heisch. 

4.  Tlie  aut-oj^Mhahnoscope, 

All  ophthalmoscopes  may  also  be  divided  into  two  principal  classes, 
the  liomo-centric  and  the  hetero-centric.  In  the  Jiomo-centric  the  mirror 
is  concave,  and  its  focus,  calculated  from  its  surface,  is  fixed  and  defi- 
nite ;  whereas  in  the  hetero-centric  the  mirror  is  plane  or  convex,  and  the 
focus  is  negative,  situated  behind  the  mirror,  and  can  be  altered  accord- 
ing to  the  strength  of  the  bi-convex  lens  which   is  fixed  beside  the 


1.— THE  PORTABLE  OR  HAND  OPHTHALMOSCOPES. 

(1.)  The  Ophthalmoscope  op  Liebreich. 

As  has  been  already  mentioned  above,  Ruete  was  the  first  to  employ 
a  concave  perforated  mirror  (which  was,  however,  fixed)  as  a  substitute 
for  the  slips  of  glass  of  Helmholtz,  and  this  principle  has  formed  the 
base  for  the  numerous  modifications  at  present  in  use.      Of  all  the 

different  forms  of  concave  mirror 
I  think  Liebreich's  (Fig.  50)  the 
most  handy  and  useful.  It  consists 
of  a  concave  metal  mirror,  about  1^ 
inch  in  diameter,  and  of  8  inches 
focal  length.  Its  centre  is  perfo- 
rated by  a  small  aperture,  about  1 
line  in  diameter,  the  edges  of  which 
are  exceedingly  thin.  The  bronze 
back  of  the  speculum  around  this 
opening  is  bevelled  off  towards  the 
edge,  so  that  the  latter  may  be  as 
thin  as  possible,  in  order  that  the 
peripheral  rays  of  the  cone  of  light 


THE   PORTABLE   OR   HAND   OPHTHALIMOSCOPES. 


291 


which  passes  tlirougli  the  apei'ture,  may  not  be  intercepted  and  cut  off 
by  a  thick  broad  edge,  wliich  would  give  the  opening  the  character  of  a 
short  canal.  Behind  the  speculum,  which  is  fixed  upon  a  short  handle, 
is  a  small  clip  for  holding  a  convex  or  concave  lens. 


(2.)  The  Ophthalmoscope  of  Coccius. 

This  instrument  consists  of  a  plane  mirror  combined  with  a  lateral 
bi-convex  collecting  lens.  Its  chief  advantages  over  the  concave  mirror 
are : — that  the  observer's  eye  is  placed  within  the  cone  of  reflected 
light,  instead  of  being  behind  it ;  that  the  focal  distance  of  the  mirror 
can  be  altered  according  as  the  lens  at  the  side  is  approximated  or 
placed  further  from  the  speculum,  or  as  the  power*  of  the  lens  is 
changed  ;  the  light  can  be  more  concentrated  upon  one  point  of  the 
retina ;  and  the  coi-neal  reflex  is  far  less.  These  advantages  over  the 
concave  mirror  are  especially  marked  in  the  examination  in  the  direct 
image.  With  the  concave  mirror,  only  a  cone  of  light  corresponding 
in  size  to  that  of  the  pupil  is  admitted  into  the  eye,  and  as  the  size  of 
this  cone  diminishes  with  the  approximation  of  the  mirror,  it  follows 
that  in  the  direct  examination  the  illumination  of  the  fundus  is  but 
slight.  Moreover,  on  account  of  the  very  close  proximity  in  which  the 
mirror  has  to  be  brought  to  the  patient's  eye,  much  of  the  light  from  the 
lamp  is  often  intercepted,  whereas  this  is  obviated  by  the  collecting  lens 
in  Coccius'  instrument.  The  latter  is,  therefore,  to  be  much  preferred 
to  the  concave  mirror  for  the  direct  method  of  examination.  For  the 
indii-ect  method  the  advantages  are  less  marked,  but  even  for  this  I 
prefer  it,  for  reasons  which  I  shall  mention  hereafter. 

Coccius'  ophthalmoscope  (Fig.  51),  as  made  at  present,  consists  of 
a  plane  metal  mirror,  having  a  small  central  aperture.  Behind  the 
mirror  is  a  hinged  clip  to  hold  a 


convex  or  concave  lens.  A  lateral 
bi-convex  lens  of  5  inches  focal 
length  is  held  in  a  large  clip 
mounted  on  a  jointed  bracket, 
which  is  so  connected  with  the 
neck  of  the  handle  that  it  permits 
of  the  lens  being  moved  to  either 
side  of  the  mirror. 

The  original  form  of  Coccius' 
ophthalmoscope  differed  from  that 
which  I  have  described  above,  and 
which  is  at  present  in  general  use, 
both  in  being  square  in  shape,  and 
in  being  made  of  glass  instead  of 


Fig.  51. 


metal.     The 


square    mirror 
u  2 


292  THE   USE   OF   THE   OPHTHALMOSCOPE. 

inconvenient,  and  could  not  be  steadied  so  well  against  the  orbit  as 
the  circular.  But  the  great  disadvantage  of  the  glass  mirror  was 
(as  Helmholtz  pointed  out)  that  the  aperture  could  not  be  bevelled 
down  to  so  fine  an  edge  as  the  metal  one,  in  consequence  of  which 
more  or  less  of  a  canal  existed,  which  intercepted  many  of  the  peri- 
pheral rays,  and  produced  considerable  diffraction. 

The  mode  of  using  Coccius'  ophthalmoscope  is  as  follows  : — The 
collecting  lens  is  to  be  turned  towards  the  flame,  which  should  be  some- 
what more  than  twice  the  distance  of  the  focal  length  of  the  lens  from 
the  observer.  The  mirror  is  then  to  be  set  somewhat  slanting  to  the 
lens  and  the  eye  of  the  patient.  If  the  mirror  is  properly  adjusted 
for  the  lens  and  the  flame,  we  shall  obtain,  if  we  throw  the  image  of 
the  flame  upon»the  palm  of  our  hand  or  the  cheek  of  the  patient,  a 
bright  circle  of  light,  with  a  small  dark  central  spot,  which  corresponds 
to  the  opening  in  the  speculum.  The  dark  spot  is  then  to  be  thrown  into 
the  pupil  of  the  eye  under  examination,  the  surgeon  placing  the  mirror 
close  to  his  own  eye,  and  looking  through  the  aperture  into  the  patient's 
eye,  which  should  afibrd  a  bright  luminous  reflex.  For  the  indirect  mode 
of  examination  a  bi-convex  lens  of  from  2  to  3  inches  focus  is  to  be  held 
before  the  eye  under  observation.  I,  moreover,  also  use  a  convex  lens 
of  8  or  10  inches  focus  behind  the  mirror,  in  order  still  more  to 
magnify  the  image.  If  the  direct  examination  is  employed,  a  concave 
lens  will  generally  be  required  behind  the  speculum.  At  first  this 
instrument  may  be  somewhat  more  difficult  to  use  than  the  concave 
mirror,  on  account  of  our  having  to  regulate  the  position  of  the  collecting 
lens  with  respect  to  the  flame  and  the  mirror ;  but  a  little  practise  and 
perseverance  will  very  soon  overcome  this  difficulty. 

(3.)  The  Ophthalmoscope  of  Zehender. 

This  consists  in  the  combination  of  a  slightly  convex  mirror  with 
a  bi-convex  collecting  lens.  The  illumination  of  the  retinal  image  is 
thus  greatly  increased,  for  the  whole  of  the  cone  of  light  reflected  from 
the  mirror  can  be  collected  into  a  narrower  section,  and  can  be  thrown 
into  the  eye  without  the  peripheral  rays  being  intercepted  by  the  edge 
of  the  pupil;  more  light  can  also  be  difi"used  over  the  fundus,  and  it 
can  be  more  strongly  concentrated  upon  one  point. 

This  ophthalmoscope  is,  in  fact,  a  modification  of  that  of  Coccius, 
and  it  very  closely  resembles  the  present  form.  Indeed,  at  the  first 
glance,  they  may  be  readily  mistaken  for  each  other.  On  closer  obser- 
vation it  will  be,  however,  noticed,  that  Zehender's  mirror  is  convex, 
whereas  that  of  Coccius  is  quite  plane.  Moreover,  on  looking  into 
Zehender's,  we  get  a  smaller  image  of  our  face  than  is  the  case  with 
that  of  Coccius.     It  is  certainly  the  best  ophthalmoscope  for  the  direct 


THE   FIXED   OPHTHALMOSCOPE   OF   LIEBREICH.  293 

examination,  but  I  prefer  Coccius'  for  the  indirect  mode  of  observation. 
Indeed,  the  latter  answers  so  well  for  both  purposes,  that  for  the  general 
surgeon  it  will  amply  suffice. 


2.— THE  FIXED  OPHTHALMOSCOPE  OF  LIEBREICH. 

This  instrument  is  constructed  upon  the  principle  of  the  concave 
m.irror  as  it  is  employed  in  the  indirect  mode  of  examination,  and  is  so 
arranged  that  the  whole  apparatus  (mirror  and  object  lens)  is  fixed  to 
a  table,  thus  allowing  the  surgeon  free  use  of  his  hands,  and  when  it  is 
properly  adjusted,  enabling  even  an  unskilled  observer  to  see  the 
details  of  the  fundus. 

The  instrument  consists  of  two  tubes,  moving  one  over  the  other. 
That  nearest  to  the  sui'geon  has  a  small  oblong  portion  cut  out  of  its 
side,  in  order  to  admit  the  light  to  the  concave  mirror,  which  is 
attached  to  its  extremity.  Behind  the  speculum  there  is  a  small  clip 
for  an  ocular  lens.  The  other  tube  carries,  at  its  free  end,  a  bi-convex 
object  lens  of  from  2  to  2^  inches  focus,  which  is  to  be  placed  about 
2J  inches  from  the  patient's  eye.  The  two  tubes  are  moveable,  one 
upon  the  other,  by  a  rack  and  pinion,  so  that  the  mirror  and  the  object 
lens  may  be  adjusted  to  any  required  distance.  The  whole  apparatus  is 
supported  on  an  upright  stem,  and  may  be  fixed  by  a  clamp  to  the  corner 
of  a  table.  This  stem  is  also  supplied  with  a  moveable  rest  to  receive 
the  patient's  chin,  and  thus  to  steady  his  head,  which  purpose  is  also 
assisted  by  a  small  arc,  supported  by  a  rod  adjusted  to  the  upper  end 
of  the  stem,  the  arc  receiving  the  patient's  forehead.  Two  small  black 
shades  are  adjusted  to  the  ttibes,  so  as  to  cut  ofi'the  light  of  the  lamp 
from  the  eyes  of  the  patient  and  the  observer.  The  lamp  is  to  be  placed 
a  few  inches  from  the  instrument,  and  nearly  oj^posite  to  the  opening  in 
the  tube  containing  the  mfrror,  so  that  its  rays  may  fall  direct  upon 
the  latter.  The  patient  is  to  be  seated  at  the  other  end  of  the  apparatus, 
having  the  eye  under  examination  on  a  level  with  the  object  lens,  and 
about  2^  inches  from  it.  Before  illuminating  his  eye,  it  will  be  best 
to  throw  the  light  upon  the  palm  of  our  hand,  upon  which  it  should 
form  a  bright  cii'cle  of  light  having  a  small  central  dark  spot ;  if 
this  is  obtained,  the  instrument  is  pi^operly  adjusted,  and  the  light 
should  be  thi'own  into  the  patient's  pupil,  which  should  be  widely 
dilated  by  atropine.  If  the  reflection  is  not  round,  but  jagged  or 
faint,  there  is  some  fault  in  the  adjustment  of  the  lamp,  mirror, 
or  object  lens,  which  must  be  corrected  before  the  examination  is 
commenced.  If  the  reflections  of  the  lamp  on  the  retina  confuse  the 
image,  the  object  lens  should  be  slightly  turned,  so  as  to  separate  the 
two  reflections  and  remove  them  from  the  centre  of  the  field  of  view. 


294  THE  USE   OF   THE   OPHTHALMOSCOPE. 

This  instrument  is  especially  useful  for  demonstration  to  a  class,  or 
for  the  purpose  of  drawing  the  appearances  of  the  fundus,  as  it  leaves 
both  hands  of  the  surgeon  at  liberty.  For  common  examination  it  is 
too  tedious  and  inconvenient,  as  we  are  completely  dependent  upon  the 
patient,  for  the  slightest  movement  of  his  eye  will  throw  the  object  out 
of  view,  whereas  with  the  hand  ophthalmoscope  we  are  chiefly  dependent 
upon  our  own  dexterity. 

A  very  excellent  modification  of  Liebreich's  instrument  has  been 
made  by  Messrs.  Smith  and  Beck,  as  suggested  by  Mr.  Kilburn.  It  is 
more  easily  adjustable,  and  its  position  with  regard  to  the  patient  and 
observer  can  be  more  readily  changed.  Instead  of  being  screwed  on  to 
the  edge  of  the  table,  this  instrument  is  fixed  upon  a  small  board  sup- 
plied with  rollers,  which  enables  its  position  to  be  changed  with  great 
facility,  and  quite  independently  of  the  patient.  Moreover,  the  standard 
carries  a  paraffin  lamp,  so  that  the  position  of  the  ophthalmoscope 
towards  the  light  always  remains  the  same,  even  although  the  former 
may  be  moved  nearer  to  or  further  from  the  patient.  This  arrange- 
ment saves  a  great  deal  of  time  and  trouble,  and  obviates  the  constant 
change  of  position  between  the  lamp  and  the  ophthalmoscope,  necessi- 
tated by  any  movement  of  the  latter.  The  rest  which  supports  the 
patient's  chin  instead  of  being  attached  to  the  instrument  is  independent 
of  it,  and  is  supported  on  a  separate  standard.  This  permits  the  position 
of  the  instrument  to  be  changed  without  affecting  that  of  the  patient. 


3.— BINOCULAR  OPHTHALMOSCOPES,  Etc. 

We  are  indebted  for  this  valuable  and  ingenious  instrument  to 
Dr.  Gii-aud-Teulon,  who  was  the  first  to  solve  the  difficult  problem  how 
it  was  possible  to  gain  a  binocular  view  of  the  details  of  the  fundus,  and 
thus  give  a  stereoscopic  effect  to  the  image. 

The  annexed  diagram  (Fig.  52)  will  explain  its  mode  of  action. 
Let  0  be  the  eye  of  the  patient,  L  the  object  lens,  and  m  n  the  concave 
mirror,  having  a  central  aperture.  Behind  the  mirror  are  two  rhombs 
(R  R)  of  crown  glass,  ground  so  as  to  affi)rd  a  double  refraction  at  an 
angle  of  45°.  These  rhombs  are  in  contact  at  the  edge  o,  thus  equally 
dividing  the  aperture  of  the  mirror.  The  efiect  of  this  arrangement  is 
that  each  pencil  of  rays  diverging  from  the  actual  image  (a)  of  the 
background  of  the  eye  after  falling  upon  the  mirror,  is  divided  into 
two — a  right  and  left  half — and  is  then  reflected  by  the  opposite  sides 
of  the  rhombs  in  such  a  manner  that  it  will  emerge  parallel  to  its 
original  direction,  and  give  rise  to  two  inverted  images  d  and  g.  The 
one  (d)  belonging  to  the  right  eye,  the  other  (g)  to  the  left.  In  order 
to  cause  these  two  images  to  become  united,  two  decentrated  lenses  are 


BINOCULAR   OPHTHALMOSCOPES. 


295 


adjusted  behind  the,  rhombs.  The  two  images  d  and  g  are  consequently 
united  at  a',  and  the  observer  thus  gains  one  stereoscopic  view  of  the 
details  of  the  fundus. 

The  disadvantage  of  this  ophthal- 
moscope, as  originally  constructed, 
was  that  as  the  rhombs  were  adjusted 
for  a  certain  fixed  distance,  it  only 
suited  persons  whose  eyes  were  a  cor- 
responding width  apart  from  each 
other ;  for  if  they  were  either  nearer 
or  further  apart  than  the  ocular 
openings,  the  surgeon  either  found 
that  one  eye  was  altogether  excluded 
from  participation  in  the  visual  act, 
or  that  he  saw  double.  This  difficulty 
has  now  been  removed,  by  a  division 
of  one  of  the  rhombs  into  two  parts, 
the  outer  of  which  is  moveable,  and 
thus  allows  of  the  instrument  being 
adapted  to  all  eyes. 

The  mode  of  using  this  instru- 
ment differs  somewhat  from  that  of 
the  ordinary  monocular  ophthalmo- 
scope. Before  attempting  to  use  it, 
the  observer  should  accurately  adjust 
it  for  his  eyes,  so  that  when  he  is 
looking  with  both  eyes  at  an  object 
he  receives  a  single,  clearly  defined 
image.  The  readiest  mode  of  adjust- 
ing the  instrument  is  to  pull  out  to  its  furthest  extent  the  screw 
at  the  end,  which  governs  the  position  of  the  moveable  half  of  the 
prism,  and  then  to  look  through  the  ocular  openings  at  the  flame 
of  a  lamp  placed  at  a  distance  of  from  12  to  18  inches.  If  the 
observer  only  sees  one  image  of  the  flame,  he  must  alternately  close 
each  eye  and  notice  whether  the  image  remains  apparent  on  the 
closure  of  either  eye;  if  so,  the  instrument  is  properly  adjusted. 
But  if  the  image  disappears  when  the  one  eye  is  shut,  it  shows 
at  once  that  the  observer  was  only  looking  through  one  ocular  open- 
ing, and  that  the  position  of  the  rhomb  must  be  changed.  If  two 
images  are  seen,  the  screw  must  be  gently  pushed  in  (or  out,  as  the  case 
may  be)  until  they  are  brought  closer  and  closer  together,  and  are  at 
last  fused  into  one  clear  and  well  defined  image,  which  must  remain 
apparent  on  the  closure  of  either  eye.  The  lamp  is  then  to  be  placed 
directly  behind  the  patient,  so  that  its  rays  may  pass  over  his  head  to 


After  Giraud-Teulon. 


296  THE  USE   OF   THE   OPHTHALMOSCOPY. 

tlie  observer,  who  is  seated  straight  before  him.  Before  the  examina- 
tion is  commenced,  the  surgeon  should  again  convince  himself  of  the 
proper  adjustment  of  the  instrument,  by  throwing  the  light  into  the 
pupil  and  noticing  whether  or  not  he  sees  one  image  of  it,  and  whether 
this  remains  apparent  when  either  eye  is  closed.  At  fii'st,  it  is  better 
to  dilate  the  pupil  with  atropine,  as  this  greatly  facilitates  the  exa- 
mination, for  even  to  an  accomj)lished  ophthalmoscopist  the  binocular 
ophthalmoscope  will  prove  somewhat  strange  at  the  commencement,  and 
will  require  to  be  used  a  few  times  before  he  becomes  thoroughly 
familiar  with  it.  In  the  more  recent  form  of  Giraud-Teulon's  instru- 
ment, the  mirror  admits  of  a  lateral  movement,  so  that  the  lamp  may 
be  placed  at  the  side  of  the  patient.  I,  however,  much  prefer  the  illu- 
mination from  above ;  still  this  is  not  always  convenient,  and  therefore 
it  is  necessary  that  the  mirror  should  have  a  lateral  movement,  more 
especially  for  the  direct  examination,  which  it  renders  more  easy. 

A  very  excellent  form  of  binocular  ophthalmoscope  has  been  invented 
by  Messrs.  Laurence  and  Heisch.  It  consists  of  a  set  of  prisms  arranged 
so  as  to  divide  the  rays  into  two.  The  two  central  prisms  are  fixed, 
but  the  two  lateral  ones  are  moveable  in  such  a  manner  that  they  not 
only  allow  of  a  lateral  movement,  but  their  inchnation  can  also  be 
changed,  so  that  the  angle  of  divergence  of  the  rays  from  the  median 
line  can  be  altered  as  may  be  necessary.  On  account  of  this  arrange- 
ment the  decentred  lenses  of  Griraud-Teulon  are  unnecessary,  and  instead 
of  these,  convex  spherical  lenses  may  be  employed,  and  the  image  be 
thus  considerably  enlarged. 

"  The  instrument*  consists  of  a  horizontal  metallic  plate  1^  centi- 
metre wide  and  10  centimetres  long,  with  a  central  perforation. 
Behind  this  plate  the  central  prisms  are  fixed,  and  the  lateral  ones  slide 
in  moveable  settings,  furnished  with  an  index  and  graduated  scale,  by 
which  their  distance  apart  can  be  read  off  at  a  glance.  Their  inclination 
is  regulated  by  a  screw  that  acts  upon  both  of  them  at  once.  The 
mirror  turns  upon  a  pin  on  the  upper  part  of  the  plate,  and  the  instru- 
ment is  completed  by  a  moveable  wooden  handle.  The  metallic  portions 
are  constructed  of  aluminium  bronze,  and  the  total  weight  is  thus 
reduced  to  2  ounces  and  50  grains.  The  case,  as  fitted  up  by  Messrs. 
Murray  and  Heath,  contains  also  an  object  lens,  and  two  pairs  of  oculars, 
and  is  made  of  a  shape  and  size  convenient  foi-  the  pocket." 

This  ophthalmoscope  possesses  certainly  several  advantages  over  that 
of  Giraud-Teulon.  In  the  first  place  it  is  much  lighter,  which  is  very 
convenient  if  numerous  cases  have  to  be  examined,  for  then  a  heavy 
instrument  proves  irksome  and  fatiguing.  Again,  on  account  of  the 
alteration  which  can  be  made  in  the  inclination  of  the  prisms,  the  strain 
upon  the  internal  recti  muscles,  in  maintaining  a  forced  convergence  in 
*  Vide  Carter's  Translation  of  Zander,  p.  61. 


BINOCULAR   OPHTHALMOSCOPES. 


297 


order  to  unite  the  double  images,  is  done  away  with.  But  this  instru- 
ment is  rather  more  apt  to  get  out  of  order  than  that  of  Giraud-Teulon, 
if  it  be  carelessly  handled,  as  is  apt  to  be  the  case  in  a  class,  where  it  is 
used  by  many  diiierent  persons. 

The  great  advantage  of  the  binocular  ophthalmoscope  consists  in 
its  affording  us  a  stereoscopic  view  of  the  details  of  the  fundus,  so  that 
they  are  brought  into  relief.  We  are  thus  enabled  to  judge  of  the 
real  thickness  of  the  retina,  and  can  readily  determine  whether 
this  is  abnormally  increased  or  diminished.  The  slightest  degrees  of 
detachment  of  the  retina  are  also  easily  recognised.  The  optic  disc 
shows  itself  in  its  reality,  and  we  can  detect  at  a  glance  whether  its 
surface  is  level,  arched  forward,  or  excavated.  Whereas,  with  the 
monocular  ophthalmoscope,  slight  changes  in  the  level  of  the  disc  are 
often  very  difficult  to  determine  with  certainty,  even  by  an  accomplished 
ophthalmoscopist.  Again,  we  can  ascertain  with  facility  the  exact 
position  of  extravasations  of  blood,  exudations  of  lymph,  or  collections  of 
pigment,  and  whether  they  are  situated  in  the  retina  or  the  choroid,  or 
perhaps  in  both  these  tissues.  These  points  in  the  differential  diag- 
nosis are  often  of  much  importance  in  framing  the  prognosis. 

Various  forms  of  aut-ophtlialmoscopes,  by  which  the  surgeon  could 
examine  his  own  eye,  have  been  devised,  the  first  who  succeeded  in  con- 
structing such  an  instrument  being  Coccius,  since  then  Heymann,  Giraud- 
Teulon,  and  Zehender  have  invented  different  kinds  of  aut-ophthalmo- 
scopes.  The  best  and  simplest  of  these  is,  I  think,  Giraud-Teulon's. 
Its  action  is  explained  by  the  accompanying  diagram  (¥ig.  63),  copied 
from  Giraud-Teulon's  article  in  the  French  translation  of  Mackenzie. 
The  instrument  consists  of  two  plane  mirrors,  m  m'  inclined  to  one 
another,  at  an  angle  of  90°,  and  placed  in  front  of  the  observer.  A 
concave  mirror  (c  c')  is 

held     obliquely    before  Fig.  53. 

the  left  eye  ((/),  so  that 
the  rays  from  a  flame 
(F)  are  reflected  on  to 
7?i,  and  thence  on  to  ««-', 
which  will  reflect  them 
into  the  right  eye  (d). 
A  double  convex  lens  I 
is  placed  between  tZ  and 
in' ,\>j  which  an  inverted 
aerial  image  of  A  is 
formed,  which  is  situ- 
ated in  reality  at  a  be- 
tween the  two  mirrors, 
but  which  will  appear 


298  THE   USE   OF   THE  OPHTHALMOSCOPE. 

to  g  to  be  situated  beyond  the  mirror  9)1  at  a".  In  fact  the  rays 
emanating  from  d,  instead  of  passing  straight  on,  are  bent  twice  at 
a  right  angle,  and  brought  back  to  g,  without  having  undergone  any 
change  in  their  relative  positions. 

4.— THE  EXAMINATION  WITH  THE  OPHTHALMOSCOPE. 

In  the  selection  of  a  portable  monocular  ophthalmoscope,  our  choice 
for  the  examination  of  the  inverted  image  lies,  I  think,  between  the 
instruments  of  Coccius  and  Liebreich.  The  latter,  on  account  of  its 
being  somewhat  easier  to  use,  is  the  one  most  generally  employed.  But 
as  certain  difficulties  in  the  use  of  the  ophthalmoscope  have  always 
to  be  overcome  by  beginners,  I  think  it  just  as  well  that  they  should 
commence  at  once  with  the  best  instrument,  even  although  the  diffi- 
culty of  the  examination  be  hereby  somewhat  enhanced.  I  have  for 
many  years  used  Coccius'  instrument  for  the  inverted  image,  in  pre- 
ference to  any  other,  as  it  possesses  certain  decided  advantages  over  the 
concave  mirror.  Thus,  on  account  of  the  lateral  collecting  lens,  we 
can  alter  the  focal  length  of  the  mirror  and  the  intensity  of  the  illu- 
mination to  any  desired  extent,  and  we  can  also  more  fully  concentrate 
the  pencil  of  light  upon  any  given  portion  of  the  fundus  which  we  wish 
to  submit  to  special  examination.  The  corneal  reflex  is  also  much  less, 
and  this  is  of  great  importance  if  the  pupil  is  very  small,  as  is  frequently 
the  case  in  elderly  people,  in  whom,  with  the  concave  mirror,  we  can 
often  obtain,  on  account  of  the  great  corneal  reflex,  but  a  very  imperfect 
view  of  the  fundus  without  artificial  dilatation  of  the  pupil. 

Coccius'  ophthalmoscope  is  also  decidedly  better  than  Liebreich's  for 
the  examination  of  the  erect  image,  although  it  is  for  this  purpose 
somewhat  inferior  to  Zehender's.  But  to  persons  who  desire  to  have 
only  one  ophthalmoscope,  which  shall  serve  them  for  all  purposes,  I 
should  recommend  that  of  Coccius  as  fulfilling  this  desideratum  better 
than  any  other. 

For  conductiag  an  ophthalmoscopic  examination,  a  darkened  room 
and  a  bright,  steady-burning  lamp  are  essentially  necessary.  In 
arranging  a  room  for  this  pui'pose  in  a  public  institution,  care  must  be 
taken  that  a  bright  stream  of  daylight  does  not  enter  directly  in  front  of 
the  patient,  as  this  produces  great  reflection,  weakens  the  illumination 
of  the  fundus,  and  renders  the  examination  far  more  difficult,  and  need- 
lessly trying  to  the  eyes  of  the  surgeon. 

The  best  gas-lamp  for  ophthalmoscopic  purposes  is  that  employed 
at  Moorfields,  which  has  an  Argand  porcelain  bui^ner,  perforated  by  a 
number  of  small  apertures,  and  closed  underneath  by  a  very  fine  wire 
gauze,  so  as  to  regulate  the  draught,  and  thus  steady  the  flame.  The 
burner  should  not  be  too  small,  but  should  give  a  full  round  flame,  as 


THE   EXAMINATION   OF   THE   ACTUAL   INVERTED   IMAGE.        290 

tins  affords  a  much  better  illumination  than  if  the  flame  is  long  and 
thin.  It  is  attached  to  a  bracket,  which  admits  of  a  universal  move- 
m,ent  in  all  directions.  In  the  consulting  room  a  standard  upright 
burner,  connected  with  a  gas  pipe  by  means  of  an  elastic  tube,  will  be, 
however,  perhaps  more  convenient.  Or  a  good,  bright-burning,  mode- 
rator lamp  may  be  employed.  The  lamp  or  bm-ner  is  to  be  covered 
only  by  a  chimney,  and  not  a  globe.  In  order  to  decrease  the  intensity 
of  the  light,  and  thus  to  diminish  the  contraction  of  the  pupil,  a  blue 
chimney  may  be  employed,  or  what  is  still  better,  a  blue  object  lens,  as 
suggested  by  Mr.  Carter,  which  is  made  by  cementing  a  plane,  light 
blue  glass  (A  tint)  between  two  plano-convex  lenses  of  the  required 
power. 

It  is  best  for  the  beginner  to  have  the  pupil  widely  dilated  by 
atropine,  as  this  greatly  facilitates  the  examination.  But  when  he  has 
acquu-ed  some  dexterity  in  the  use  of  the  ophthalmoscope,  he  must  learn 
to  examine  with  an  undilated  pupil ,  for  the  use  of  atropine  proves 
very  inconvenient  to  the  patients.  It  should,  therefore,  only  be  employed 
exceptionally,  and  when  it  is  essentially  necessary,  as  for  instance  when 
the  pupQ  is  very  small,  and  the  periphery  of  the  fundus  has  to  be 
examined  for  a  suspected  slight  detachment  of  the  retina,  or  morbid 
changes  in  the  outlying  portions  of  the  choroid  and  retina.  The  exami- 
nation in  the  region  of  the  yellow  spot  is  also  very  difficult,  on  account 
of  the  great  reflection  of  the  light,  and  the  great  contraction  of  the 
pupil  when  this  part  of  the  eye  is  illuminated.  If  atropine  is  used, 
only  a  very  weak  solution  should  be  employed,  otherwise  the  dilatation 
of  the  pupil  will  not  only  last  some  time,  but  there  will  also  be  much 
inconvenience  from  the  paralysis  of  the  accommodation,  which  will, 
perhaps,  prevent  the  patient  from  usiag  his  eyes  for  reading  and  writing 
for  several  days.  For  the  purpose  of  simply  dilating  the  pupil  for 
ophthalmoscoping,  a  drop  of  a  solution  of  1  grain  of  atropine  to  10  or 
12  ounces  of  water  will  suffice  to  produce  the  requisite  degree  of  dila- 
tation in  about  an  hour,  and  it  will  continue  from  12  to  30  hours.  The 
atropinized  gelatine  discs  will  be  found  very  convenient,  as  the  patient 
can  himself  place  one  in  the  eye,  before  his  visit  to  the  surgeon. 

5.— THE   EXAMINATION   OF   THE   ACTUAL  INVERTED 

IMAGE. 

The  patient  is  to  be  seated  on  a  chair,  and  the  lamp  should  be 
placed  beside,  and  somewhat  behind  him,  at  the  side  corresponding  to 
the  eye  which  is  to  be  examined.  The  surgeon  then  seats  himself 
directly  opposite  to  the  patient,  and,  holding  the  mirror  in  his  right 
hand,  places  it  close  before  his  eye,  so  that  its  upper  edge  rests  against 
the  superior  margin  of  the  orbit.     Then  turning  the   mirror  slightly 


300  THE   USE   OF   THE  OPHTHALMOSCOPE. 

towards  the  lamp,  lie  throws  the  reflection  of  the  flame  into  the  eye, 
the  pupil  of  which  will  be  brightly  illuroinated.  This  movement  of 
the  mirror  must  be  very  slight,  and  simply  made  by  rotating  the  handle 
a  very  little  between  the  fingers,  otherwise  the  reflection  will  be  thrown 
considerably  above  or  to  the  side  of  the  patient's  head.  The  beginner 
always  finds  some  difficulty  in  acquiring  these  slight  movements  of  the 
mirror,  as  also  the  power  of  moving  his  own  head  in  difierent  direc- 
tions, and  yet  keeping  the  eye  constantly  well  illuminated.  When  the 
fundus  is  thoroughly  lighted  up,  the  rim  of  the  bi-convex  object  lens 
is  to  be  taken  lightly  between  the  forefinger  and  thumb  of  the  left 
hand,  and  held  about  two  inches  from  the  eye  under  examination.  The 
ring  finger  is  to  be  placed  against  the  upper  edge  of  the  orbit,  in  order 
to  steady  the  hand,  and  this  leaves  the  little  finger  free  for  lifting  the 
upper  lid  if  necessary.  The  object  lens  should  be  held  at  such  a  dis- 
tance from  the  eye  that  its  focal  length  coincides  with  the  pupil.  A 
2-inch  lens  should,  therefore,  be  held  a  little  less  than  two  inches  from 
the  cornea,  and  a  3-inch  lens  a  little  less  than  three  inches.  At  first, 
some  difiiculty  is  always  experienced  in  keeping  the  eye  illuminated 
during  the  adjustment  of  the  object  lens,  as  the  observer's  attention  is 
apt  to  be  entirely  dii-ected  to  it,  and  he  forgets  all  about  the  illumina- 
tion. Indeed  one  of  the  chief  difliculties  that  the  beginner  has  to 
overcome,  is  that  of  learning  to  work  both  hands  readily  together. 

When  the  fundus  is  well  illuminated,  we  should  first  endeavour  to 
gain  a  view  of  the  optic  disc,  and  the  patient  should  therefore  be 
directed  to  look  at  the  ear  of  the  observer  which  is  on  the  opposite  side 
to  the  eye  under  examination,  so  that  the  optic  axis  of  the  latter  may 
be  turned  somewhat  inwards.  Thus  if  the  right  eye  is  to  be  examined, 
the  patient  should  look  towards  the  surgeon's  right  ear,  and  vice  versa. 
For  as  the  entrance  of  the  optic  nerve  is  not  situated  in  the  optic  axis 
(centre  of  the  retina),  but  towards  its  nasal  side,  it  is  necessary  that  the 
patient  should  look  inwards,  in  order  that  the  disc  maybe  brought  directly 
opposite  to  the  observer's  eye.  To  gain  this  position,  the  patient. may 
also  be  directed  to  look  at  the  uplifted  little  finger  of  the  hand  holding 
the  ophthalmoscope.  In  this  case  its  handle  may  be  held  horizontally, 
and  the  left  hand  used  for  holding  the  mirror  when  the  left  eye  is 
under  examination.  It  is  still  more  convenient  to  have  a  screen  or  board, 
divided  into  differently-numbered  compartments,  placed  at  some  dis- 
tance behind  the  surgeon.  The  patient  is  then  directed  to  look  at  a 
certain  figure  upon  the  board,  according  to  the  part  of  the  fundus 
which  we  desire  to  examine.  The  object  should  always  be  placed  at 
some  distance,  in  order  that  the  patient's  accommodation  may  be  relaxed 
to  the  utmost.  The  entrance  of  the  optic  nerve  is  readily  recognised 
by  its  presenting  a  whitish  reflex,  instead  of  the  red  glare  reflected 
from  the  fundus.     As  soon  as  this  white  reflex  is  obtained,  the  object 


THE  EXAMINATION   OF   THE   ACTUAL   INVERTED   IMAGE.      301 

lens  should  be  adjusted,  and  we  shall  then  have  no  difficulty  in  finding 
the  optic  nerve  entrance,  which  appears  in  the  form  of  a  circular 
pinkish-white  disc,  on  whose  expanse  are  noticed  numerous  blood- 
vessels, which  diverge  from  it  to  be  distributed  to  different  portions  of 
the  retina.  If  the  disc  is  not  in  view,  it  may  also  be  easily  found  by 
tracing  some  of  the  retinal  vessels  up  to  the  point  towards  which  they 
converge — i.  e.,  the  optic  nerve  entrance.  The  disc  having  been  found, 
the  observer  should  very  carefully  study  its  colour,  the  appearance  of 
its  surface  and  margin,  and  the  course  of  the  blood-vessels  upon  it,  in 
order  that  these  different  points  may  be  well  impressed  upon  his 
memory.  In  the  next  place,  passing  from  the  disc,  the  different  por- 
tions of  the  fundus  should  be  successively  examined,  and  the  appearance 
and  mode  of  distribution  of  the  retinal  vessels,  and  the  difference  between 
them  and  those  of  the  choroid  be  carefully  studied.  The  beginner 
should  always  examine  at  first  a  considerable  number  of  healthy  eyes ; 
to  study  very  attentively  the  physiological  appearances  of  the  fundus, 
and  the  various  peculiarities  which  may  occur  within  normal  limits. 
And  then,  when  he  has  become  thoroughly  conversant  with  these 
diversities,  he  should  pass  on  to  the  examination  of  the  pathological 
conditions.  The  examination  of  the  rabbit's  eye,  also  affords  excellent 
practice,  and  in  the  Albino  rabbit  the  distribution  of  the  choroidal  and 
retinal  vessels  can  be  most  beautifully  seen.  As  the  opportunity  of 
examining  a  considerable  number  of  human  eyes  is  not  always  to  be 
had,  the  following  instrument,  made  by  IS'achet  of  Paris,  will  be  found 
extremely  useful  for  practising  ophthalmoscopy,  and  for  studying  many 
of  the  morbid  appearances  of  the  fundus.  It  consists  of  an  artificial 
eye,  or  dummy,  made  of  brass,  and  fitted  in  front  with  a  lens  in  the 
situation  of  the  cornea.  This  lens  is  covered  with  a  black  metal  cap, 
having  a  central  aperture  corresponding  to  the  pupil.  There  are  two 
of  these  caps,  the  one  having  a  very  small  central  opening  correspond- 
ing to  the  normal  size  of  the  pupil ;  the  other  a  large  aperture,  like  a 
■widely  dilated  pupil.  By  changing  the  lens,  we  may  convert  the  eye 
into  a  hypeiTQctropic,  myopic,  or  astigmatic  one.  The  posterior  half  of 
the  eye  opens,  so  as  to  admit  of  the  insertion  of  a  papier  mache  cup  or 
disc,  coloured  to  represent  the  appearance  of  a  healthy  fundus,  or 
of  some  pathological  condition,  as  for  instance,  retinitis  pigmentosa, 
excavation  of  the  optic  nerve,  posterior  staphyloma,  etc.  In  the 
box  containing  the  instrument,  there  is  a  series  of  these  coloured 
discs,  illustrating  many  of  the  morbid  ophthalmoscopic  appearances  of 
the  fundus.  The  eye  is  fixed  upon  a  standard  for  placing  it  upon  a 
table. 

I  have  already  mentioned,  that  if  we  desire  to  increase  the  size  of 
the  image  in  the  indirect  mode  of  examination,  we  must  employ  a 
weaker  object  lens,  e.g.,  of  3  or  4  inches  focus,  which  must  be  held 


302  THE  USE   OF   THE   OPHTHALMOSCOPE. 

somewhat  farther  from  the  eye.  In  order  to  magnify  the  image  still 
more,  Coccius*  has  devised  a  compound  object  lens  which  consists  of 
two  convex  lenses  (one  of  which  has  a  focal  length  of  2,  the  other 
of  2^  inches),  inserted  in  tha  extremities  of  a  brass  tube,  composed 
of  two  portions,  each  of  which  is  2^  inches  in  length,  and  made  to 
slide,  one  within  the  other.  The  effect  of  this  is,  that  parallel  rays 
reflected  from  an  emmetropic  eye  will  be  united  within  the  tube  into 
an  actual  inverted  image,  th«  rays  from  which  will  then  pass  through 
the  second  lens,  which  will  afford  a  magnified  virtual  image  of  the 
actual  image  within  the  tube.  The  disadvantages  of  this  compound 
object  lens  are,  that  it  is  expensive,  and  very  cumbersome,  proving 
very  fatiguing,  if  many  patients  have  to  be  examined  in  succession. 
I  find,  moreover,  that  we  may  gain  almost  as  great  an  enlargement, 
by  using  an  ordinary  object  lens  of  four  inches  focus,  and  a  convex 
lens  of  eight  inches  focus  behind  the  mirror. 

6.— THE  EXAMINATION  OF  THE  VIRTUAL  ERECT  IMAGE. 

It  has  already  been  stated,  that  in  this  mode  of  examination  the 
observer  must  go  very  close  to  the  patient's  eye.  The  lamp  must 
therefore  be  placed  on  the  side  corresponding  to  the  eye  under  exami- 
nation, and  the  surgeon  will  find  it  most  convenient  to  examine  with 
his  right  eye  the  corresponding  eye  of  the  patient,  and  vice  versa.  For 
the  examination  of  the  erect  image  the  ophthalmoscope  of  Coccius  or 
Zehender  will  be  found  preferable  to  that  of  Liebreich.  Not  only  is 
the  illumination  better,  and  the  corneal  reflex  considerably  less,  but  it 
is  also  easier,  on  account  of  the  lateral  collecting  lens,  to  maintain 
a  good  illumination  of  the  eye,  and  to  keep  the  optic  axis  of  the 
observer's  eye  in  a  line  corresponding  to  that  of  the  patient,  which  is 
often  difficult,  if  the  miiTor  has  to  be  considerably  turned  in  order  to 
catch  the  rays  from  the  lamp.  If  the  surgeon  is  not  much  accustomed 
to  this  mode  of  examination,  and  the  pupil  is  small,  the  latter  should 
be  dilated  with  atropine,  for  this  will  increase  the  size  of  the  field 
of  vision,  and  facilitate  the  lighting  up  of  the  fundus.  If  the  observer 
and  the  patient  are  both  emmetropic,  and  their  accommodation  is  sus- 
pended (i.e.,  if  they  are  accommodated  for  their  far  point,  in  this  case 
for  parallel  rays)  the  surgeon  will  receive  a  clearly  defined  and  dis- 
tinct image  of  the  details  of  the  fundus.  The  beginner,  however, 
generally  finds  considerable  difficulty  in  completely  relaxing  his  accom- 
modation, more  especially  as  his  close  approximation  to  the  patient 
leads  him  involuntarily  to  accommodate  for  a  point  considerably  nearer 
than  his  far  point,  i.e.,  he  is  accommodated  for  more  or  less  divergent 

*  Mr.  R.  Carter  has  given  an  excellent  description  of  this  apparatus  and  its 
mode  of  action  in  the  "Lancet,"  March  18,  1865. 


THE   EXAMINATION   OF   THE   VIRTUAL   ERECT   IMAGE.         303 

rays.  This  will  render  the  image  indistinct,  and  necessitate  the  use  of 
a  concave  ocular  lens,  in  order  to  give  the  requisite  degree  of  diver- 
gence to  the  parallel  rays  emanating  from  the  patient's  eye.  In  certain 
conditions  of  the  refraction  either  of  the  patient's  or  surgeon's  eye,  a 
concave  ocular  lens  is  absolutely  necessary  to  render  the  image  of  the 
fundus  distinct.  Thus,  if  the  patient's  eye  is  emmetropic,  but  that  of 
the  surgeon  myopic,  the  rays  from  the  former  will  be  parallel,  and  be 
consequently  brought  to  a  focus  in  front  of  his  retina,  and  a  concave 
lens  will  be  required  to  give  them  the  necessary  degree  of  divergence. 
The  strength  of  this  lens  should  be  such  as  to  neutralize  his  myopia 
for  distance.  A  still  stronger  concave  lens  will  be  required,  if  the  eyes 
of  the  surgeon  and  patient  are  both  rajo-pic,  for  then  the  rays  will 
impinge  in  a  convergent  direction  upon  the  surgeon's  eye.  But  if  the 
surgeon  is  myopic,  and  the  patient  hypermetropic,  the  former  may  be 
able  to  see  the  fundus  distinctly  without  the  aid  of  a  concave  lens  for 
the  following  reason : — the  focus  of  the  dioptric  system  of  the  eye 
under  examination,  will  in  this  case  lie  behind  the  retina,  and  the  eye 
will  therefore  be  adjusted  for  more  or  less  convergent  rays.  The 
emerging  rays  will  consequently  be  divergent,  and  will  be  readily 
united  upon  the  observer's  retina,  if  his  myopia  is  not  too  considerable 
in  degree.  The  same  would  occur  if  the  surgeon  were  hypermetropic 
or  emmetropic,  but  then  he  would  have  to  use  his  power  of  accommo- 
dation, in  order  to  bi-ing  the  divergent  rays  to  a  focus  upon  his  retina. 
If  on  the  other  hand  the  observer  is  hyjjermetropic,  he  may  also  be  able 
to  examine  a  myopic  or  emmetropic  eye  (if  the  myopia  is  not  too 
great)  without  the  aid  of  a  concave  lens,  for  he  will  be  able  to  unite 
convergent  rays  upon  his  retina,  and  also  parallel  rays  by  an  effort  of 
the  accommodation.  The  cases  containing  the  portable  ophthalmos- 
copes are  supplied  with  a  series  of  concave  ocular  lenses,  varying  in 
focal  length  from  4  to  10  or  12  inches,  and  fitting  into  the  clip 
behind  the  mirror.  The  surgeon  should  select  the  strength  of  the 
lens  according  to  the  state  of  the  refraction  of  his  o-\vn  and  the 
patient's  eye. 

The  chief  advantage  of  the  erect  image  is,  that  we  obtain  a  much 
larger  image,  so  that  the  minute  details  of  the  fundus  can  be  studied 
with  much  greater  accuracy.  This  mode  of  examination  is  therefore  of 
much  importance  in  solving  any  doubts  which  may  exist  with  the 
reverse  image,  as  to  the  exact  nature  or  situation  of  any  morbid  appear- 
ances. But  the  field  of  vision  is  more  limited,  and  the  examination 
somewhat  more  difiicult.  Moreover,  it  is  not  always  convenient  or 
agreeable  to  examine  all  patients  in  such  close  proximity.  The  latter 
may  be  one  reason  why  this  mode  of  examination  is  far  too  much 
neglected  in  England  in  favour  of  the  inverted  image.  As  a  rule,  it  is 
best  to  obtain  a  general -view  of  the  appearances  of  the  fundus  in  the 


304  THE  USE   OF   THE   OPHTHALMOSCOPE. 

inverted  image,  and  then,  if  we  desire  to  examine  any  particular  point 
with  greater  minuteness  and  accuracy,  to  have  recourse  to  the  dii'ect 
method. 


7.— THE    OPHTHALMOSCOPIC    APPEARANCES    OF 
HEALTHY  EYES  (Plate  I,  Figs.  1,  2). 

Before  commencing  any  ophthalmoscopic  examination  of  the  fundus, 
the  condition  of  the  cornea,  iris,  pupil,  and  crystalline  lens  should  be 
examined  by  the  obHque  illumination.  This  having  been  done,  the  same 
structures  should  be  viewed  by  transmitted  light,  i.e.,  the  surgeon 
should  examine  the  eye  by  the  direct  method  (without  the  interposition 
of  a  convex  lens  between  the  mirror  and  the  patient's  eye),  but  the 
mirror  should  be  held  at  some  distance  (14  or  18  inches)  from  the  eye 
under  examination.  In  this  way  no  opacity  of  the  refracting  media  can 
escape  detection,  which  is  not  unfrequently  the  case  if  these  modes  of 
examination  are  neglected,  and  the  fundus  only  examined  with  the 
inverted  image.  We  can  also  in  this  way  readily  ascertain  the  state  of 
refraction  of  the  eye. 

The  examination  of  the  refracting  media  in  a  healthy  condition,  of 
course  affords  a  negative  result.  Sometimes  small  flakes  of  mucus  may 
be  noticed  on  the  cornea,  giving  it  a  somewhat  irregular  appearance. 
They  disappear  on  closure  of  the  lids. 

It  has  been  already  stated  (p.  218)  that  certain  physiological 
changes  occur  in  the  lens  in  advancing  age,  and  we  must  be  upon  our 
guard  not  to  mistake  these  for  commencing  cataract.  The  lens  substance 
becomes  thickened  and  consolidated,  and  the  nucleus  assumes  a  yellowish 
tint,  which  is  especially  apparent  by  reflected  light.  Indeed  this  opacity 
is  sometimes  so  considerable,  that  it  may  be  mistaken  for  a  tolerably 
advanced  cataract,  but  on  examining  the  lens  by  transmitted  light 
(with  the  mirror  only)  it  will  be  found  perfectly  transparent,  and  the 
details  of  the  fundus  qtiite  distinct. 

On  the  other  hand,  the  healthy  appearances  presented  by  the  fundus 
oculi  deserve  and  demand  the  closest  and  most  attentive  study,  in  order 
that  the  many  diversities  which  they  may  present  may  not  be  mistaken 
for  morbid  phenomena.  It  is  only  by  an  intimate  knowledge  of  the 
many  physiological  peculiarities  which  may  exist  in  a  perfectly  normal 
eye,  that  we  can  avoid  committing  grave  errors  in  diagnosis.  Beginners 
are  but  too  apt  to  hurry  over  the  examination  of  healthy  eyes  with 
a  careless,  "  Oh,  there  is  nothing  the  matter ;  the  fundus  is  quite 
healthy,"  craving  only  after  the  most  marked  pathological  changes, 
such  as  large  posterior  staphylomata,  very  deep  excavations  of  the  optic 
nerve,  and  huge,  patches  of  atrophied  choroid ;  and  completely  over- 
looking the  minuter  shades  of  difference  between  a  healthy  and  morbid 


OPHTHALMOSCOPIC   APPEARANCES   OF   HEALTHY  EYES.        305 

condition  of  the  fundus,  a  knowledge  of  wliicli  proves  of  the  greatest 
importance  in  practice. 

On  looking  at  No.  1  of  the  ophthalmoscope  plates,  the  reader 
will  be  at  once  struck  by  the  marked  difference  in  the  appearances 
presented  by  Figs.  1  and  2,  and  yet  both  illustrate  a  perfectly  healthy 
fundus. 

In  Fig.  1  (which  is  taken  fi'ora  a  person  with  black  hair  and  a  dark 
brown  iris)  the  optic  nerve  entrance  appears  cii'cular,  and  of  a  yellowish. 
white  tint.  The  blood-vessels  emerge  somewbat  to  the  left  of  the  centre 
of  the  disc,  which  is  here  of  a  deeper  white.  The  paler  vessels  are  the 
retinal  arteries,  the  darker  ones  the  veins.  They  pass  over  the  disc  to 
the  retina,  where  they  course  and  divide  in  different  directions,  chiefly 
upwards,  downwards,  and  towards  the  left.  At  some  little  distance  to 
the  right  of,  and  slightly  below  the  disc,  is  noticed  a  large  dark  red 
spot,  with  a  small  white  dot  in  the  centre.  This  is  the  macula  lutea,  or 
yellow  spot,  with  its  foramen  centrale.  It  will  be  observed  that  the 
vessels  course  round  the  yellow  spot,  leaving  it  free.  The  fine  grey  film 
in  the  region  of  the  disc  and  the  yellow  spot  is  due  to  the  reflex  yielded 
by  the  retina ;  it  is  only  observable  in  dark  eyes,  and  is  consequently 
altogether  absent  ia  Fig.  2.  The  fundus  of  the  eye  is  of  a  rich  dark  red 
tint,  and  only  the  retinal  vessels  are  apparent,  those  of  the  choroid  being 
hidden  by  the  density  of  the  pigment  in  the  epithelial  layer  and  stroma 
of  the  choroid. 

In  Fig.  2  (taken  from  the  eye  of  a  person  with  very  light  hair  and  a 
blue  iris)  the  appearances  are  quite  different.  The  disc  is  of  a  more 
rosy  tint,  the  retinal  vessels,  although,  very  distinct,  are  less  markedly 
so  than  on  the  darker  background  of  Fig.  1.  The  region  of  the  yellow 
spot  is  of  a  bright  red  colour,  and  the  foramen  centrale  appears  in  the 
form  of  a  little  light  circle.  But  the  greatest  difference  is  noticed  in 
the  pale,  brilliantly  red  colour  of  the  fundus,  and  the  distinctness  with 
which,  the  finest  branches  of  the  choroidal  vessels  can  he  traced.  The 
ciliary  arteries  enter  ia  the  region  of  the  yellow  spot,  and  running 
towards  the  periphery  ramify  in  various  dii'ections,  and  partly  pass  over 
directly  into  the  larger  branches  of  the  vasa  vorticosa,  situated  at  the 
equator  of  the  eye. 

The  red  coloui'  of  the  background  of  the  eye,  as  seen  with  the 
ophthalmoscope,  is  due  to  the  reflection  of  the  light  from  the  blood- 
vessels of  the  retina  and  choroid,  more  especially  the  latter.  As  the 
retina  is  very  translucent,  but  little  light  is  reflected  by  it,  and  the 
sclerotic  can  only  be  seen  through  the  choroid,  and  will  therefore  be  the 
more  apparent  the  less  pigment  there  is  in  the  latter.  The  appearance 
presented  by  the  fundus  will,  therefore,  vary  greatly  according  to  the 
degree  of  pigmentation  of  the  choroid.  If  its  epithelial  layer  and 
stroma  are  darkly  pigmented,  the  vessels  of  the  choroid  may  be  com- 

X 


306  THE   USE   OF   THE   OPHTHALMOSCOPE. 

pletely  hidden,  even  at  the  periphery  of  the  fandus.  But  if  the  epithe- 
lial layer  contains  but  Kttle  pigment,  and  the  stroma  is,  on  the  other 
hand,  richly  pigmented,  the  choroidal  vessels  will  appear  like  bright  red 
bands  or  ribbons,  divided  by  dark  islets  or  intervals,  the  so-called  intra- 
vascular spaces.  These  vessels  are  chiefly  situated  in  the  stroma  of 
the  choroid,  for  they  are  less  covered  by  the  pigment  than  those  of 
the  venee  vorticosEe,  -which  lie  deeper  (nearer  the  sclerotic),  or  the  smaller 
vessels  (Schweigger).  The  intravascular  spaces  are  of  a  longitudinal 
shape  near  the  equator  of  the  eye,  and  more  oval  or  circular  in  the 
vicinity  of  the  disc.  If  the  stroma  is  light,  and  the  epithelium  but 
moderately  pigmented,  the  epithelial  cells  may  be  well  seen  with  a 
considerable  magnifying  power,  as  has  been  shown  by  Liebreich,  and 
may  be  recognised  as  small  cu'cumsciibed  dots  uniformly  studded  over  the 
fundus,  giving  it  a  markedly  granular  appearance.  In  eyes  in  which  the 
pigmentation  of  the  choroid  is  but  very  slight,  the  choroidal  vessels  may 
be  most  beautifully  traced  to  their  smallest  divisions,  as  also  the  large 
stems  of  the  ven«  vorticos^e  as  they  perforate  the  sclerotic.  The  red 
colour  of  the  background  is  also  influenced  by  age  and  the  illumination. 
It  is  of  a  brighter  tint  in  young  persons  than  in  older  individuals. 
If  the  illumination  is  strong,  the  brightness  will  be  uniform,  if  it  is 
weaker,  it  will  decrease  from  the  disc  towards  the  periphery  of  the 
fundus. 

The  retina  is  extremely  translucent,  and  reflects  but  little  light.  On 
this  account  it  is  not  visible  in  light  eyes,  biit  becomes  so  when  the 
fundus  is  dark,  appearing  like  a  thin  grey  film  or  halo  over  the  back- 
ground. In  very  dark  eyes,  such  as  those  of  negroes,  the  retina  is  very 
distinctly  apparent,  showing  a  grey  striated  appearance,  especially  in 
the  vicinity  of  the  disc.  The  striae  are  not,  Schweigger  thinks,  due  to 
the  nerve  fibres,  but  to  the  peculiar  arrangement  of  the  connective  tissue. 

8.— THE  OPTIC  DISC. 

The  normal  disc  is  subject  to  numerous  and  sometimes  marked 
difierences  in  shape,  colour,  and  size.  An  exact  knowledge  of  all  the 
peculiarities  which  come  within  the  normal  and  physiological  standard 
is  absolutely  necessary  to  prevent  the  surgeon  from  falling  into  eiTors 
in  diagnosis,  and  mistaking  some  perfectly  physiological  appearances  as 
being  of  pathological  import. 

The  entrance  of  the  optic  nerve  is  generally  round,  but  not  perfectly 
circular;  it  is  often  oval,  having  the  long  diameter  vertical.  This  oval 
appearance  is  particularly  striking  in  cases  of  astigmatism.  The  disc  is 
generally  of  a  transpareut,  greyish-pink  tint,  with  a  slight  admixture 
of  blue.  This  tint  varies  in  appearance  with  the  pigmentation  of  the 
choroid;  thus  iu  dark  eyes  the   disc   appears   white  and   glistening. 


1 


THE   OPTIC   DISC,  307 

"whereas  in  very  liglit  eyes  it  assumes  a  more  rosy  hue.  The  admixture 
of  the  colour  of  the  optic  nerve  entrance  is  made  up  from  three  sources  ; 
the  white  is  due  to  the  reflection  from  the  connective  tissue  of  the 
lamina  cribrosa,  the  red  to  the  blood  in  the  capillaries  on  its  expanse,  and 
the  bluish-grey  to  the  nerve  tubules  l}"ing  in  the  meshes  of  the  cribriform 
tissue.  The  outline  of  the  disc  appears  sharply  defined,  but  on  closer 
observation  Ave  notice  that  it  may  be  divided  into  an  internal  grey  ring, 
the  real  boundary  of  the  nerve ;  outside  this,  is  the  white  line  of  the 
sclerotic  ring,  which  varies  somewhat  in  size,  being  broadest  and  most 
apparent  at  the  outer  side  of  the  disc.  External  to  the  scleral  zone,  is 
the  dark  grey  line  of  the  opening  in  the  choroid.  This  choroidal  ring 
is  somewhat  irregular  in  shape  and  colour,  being  most  marked  at  the 
outer  side,  at  which  there  is  often  a  well  defined  deposit  of  pigment 
molecules,  assuming  the  appearance  of  a  broad  black  crescent,  which  is 
frequently  mistaken  by  beginners  for  some  pathological  change. 

The  retinal  vessels  generally  emerge  from  the  central  portion  of  the 
disc,  or  somewhat  to  the  inner  side  of  it.  If  the  division  of  the  central 
artery  takes  place  after  its  passage  through  the  lamina  cribrosa,  the 
division  of  the  main  trunk  into  the  different  branches  can  be  distinctly 
observed.  Whereas,  if  the  division  occurs  before  the  passage  of  the 
trunk  through  the  lamina  cribrosa,  the  main  branches  pierce  the  disc 
in  an  isolated  manner,  so  that  their  point  of  division  from  the  trunk 
cannot  be  distinguished.  The  number,  mode  of  division,  and  course  of 
the  retinal  vessels  vary  very  considerably,  being  constant  only  in  this, 
that  the  principal  branches  run  upwards  and  downwards.  As  a  rule,  no 
main  branch  runs  inwards,  but  only  a  considerable  nrmiber  of  smaller 
vessels ;  whereas  towards  the  outer  side  only  a  few  very  small,  short 
twigs  are  sent.  The  most  frequent  arrangement  is  that  an  artery  and 
two  veins  pass  upwards,  and  the  same  downwards  ;  but  sometimes  there 
are  two  arteries  and  two  veins.  The  arteries  may  be  readily  dis- 
tinguished from  the  veins  by  being  lighter  in  colour,  smaller,  and 
straighter  in  their  course.  Moreover,  along  the  centre  of  the  vessel  is 
noticed  a  bright  streak,  so  that  the  artery  appears  to  have  a  double 
outline,  this  bright  stripe  being  due  to  the  reflection  of  light  from  the 
cylindrical  wall  of  the  vessel.  The  retinal  veins  are  of  a  darker  tint, 
larger,  and  more  undulating  than  the  arteries.  On  account  of  the 
greater  tenuity  of  the  walls  of  the  veins,  and  of  the  blood-tension 
being  less  in  them  than  in  the  arteries,  they  are  somewhat  flattened 
and  not  cylindrical  in  form.  Hence  the  reflection  of  light  is  very  slight, 
and  the  central  bright  streak  hardly  observable.  The  blood  supply  of  the 
most  anterior  part  of  the  optic  nerve  is  maintained  not  only  by  the  small 
twigs  given  off  to  it  from  the  central  vessels  of  the  retina,  but  also  by  a 
series  of  branchlets  emanating  from  a  vascular  circle,  which  is  situated 
close  to  the  edge  of  the  optic  nerve,  and  which  is  formed  by  three  or  four  of 

x2 


308  THE   USE   OP   THE   OPHTHALMOSCOPE. 

the  short  posterior  ciliary  arteries.*  Leber,  moreover,  has  found  that 
numerous  arteries  and  some  veins  also  pass  directly  from  the  choroid  to 
the  optic  nerve,  anastomosing  there  with  the  network  of  vessels  which 
surrounds  the  nerve  fibres. 

On  closely  regarding  the  surface  of  the  disc,  we  notice  that  its 
colour  varies  at  different  points,  and  that  it  presents,  moreover,  towards 
the  outer  side,  a  somewhat  mottled  greyish-white  appearance.  This 
grey  stippling  is  produced  by  the  nerve  tubules  seen  in  section,  and 
the  white  dots  or  lines  between  them  are  due  to  the  trabeculae  of  the 
sieve-like  lamina  cribrosa.  At  the  point  of  exit  of  the  retinal  vessels 
the  white  appearance  is  very  marked,  and  often  presents  a  little  pit  or 
hollow.  Whilst  the  outer  portion  of  the  disc  presents  a  mottled  greyish- 
white  appearance,  the  inner  half  assumes  a  much  redder  tint.  The 
reason  of  this  is  easily  explained.  As  a  greater  number  of  the  optic 
nerve  fibres,  after  the  entrance  of  the  optic  nerve  into  the  eye,  bend 
over  to  the  inner  side,  the  transparency  of  this  portion  of  the  nerve  is 
much  diminished  by  this  close  super- imposition  of  the  fibres,  and  hence 
the  details  of  the  lamina  cribrosa  are  hidden.  "Whereas,  on  the  outer 
half  the  latter  are  still  very  evident,  as  the  layer  of  nerve  fibres  is  here 
much  less  considerable  and  more  arched  upwards  and  downwards,  and 
the  white  reflection  consequently  much  more  marked.  Inattention  to 
these  facts  may  lead  the  observer  into  considerable  errors  of  diagnosis. 
He  may  consider  the  normal  redness  of  the  inner  half  of  the  disc  as 
pathological,  and  assume  the  presence  of  hyperemia,  or  even  inflamma- 
tion of  this  part  of  the  nerve  ;  or  he  may  mistake  the  white  appearance 
of  the  outer  half  for  commencing  atrophy. 

We  must  now  notice  two  peculiarities  of  the  optic  disc  which  are 
often  met  with  in  perfectly  healthy  eyes,  viz.,  1,  spontaneous  or  easily 
producible  pulsation  of  the  retinal  veins ;  2,  physiological  excavation 
of  the  optic  nerve. 

The  venous  pulsation  is  characterised  by  an  alternating  increase  and 
diminution  in  the  calibre  of  the  vein.  The  emptying  of  the  vein  com- 
mences at  the  centre  of  the  optic  disc,  and  extends  to  the  periphery ;  the 
re-filling,  on  the  other  hand,  begins  at  the  periphery  and  extends 
towards  the  centre.  The  venous  pulsation  is  generally  only  visible  in 
the  expanse  of  the  disc,  but  in  very  rare  cases  it  may  even  extend 
beyond  its  margin.  It  exists  probably  in  all  eyes,  but  does  not  gene- 
rally appear  spontaneously.  The  pulsation  may,  however,  be  made  ap- 
parent, or  rendered  more  marked  and  distinct,  by  slight  pressure  with 
the  finger  upon  the  eyeball,  and  we  may  thus  alternately  produce  a 
complete  emptying  and  re-filling  of  the  vein.  On  a  sudden  relaxation 
of  pressure  which  lias  been    continued    for   a    little    time,    the  veins 

*  Vide  Jiigov,  "  EinstcUung  des  dioptrisclicn  Apparates,"  p.  55 ;  also  Leber, 
"A.  f.  O.,"  xi,  1,  5. 


THE   OPTIC   DISC.  309 

become  rapidly  over-filled  and  swollen,  this  dilatation  lasts  for  about  a 
minute,  and  then  they  resume  their  normal  calibre.  The  respiration 
also  som.ewhat  affects  the  retinal  circulation ;  thus,  an  increase  in  the 
size  of  the  vein  may  be  noticed  during  strong  expiration,  whereas  a 
deep  inspiration  causes  it  to  diminish.  The  vein  and  artery  are  in  an 
opposite  state  of  fulness,  the  arterial  systole  being  synchronous  with 
the  venous  diastole. 

Whilst  spontaneous  pulsation  of  the  retinal  veins  is  a  perfectly 
physiological  phenomenon,  this  is  not  the  case  with  the  arterial  pulsa- 
tion, for  this  only  exists  when  the  intra-ocular  tension  is  abnormally 
increased.  It  is,  therefore,  a  symptom  of  great  importance  in  the 
diagnosis  of  a  glaucomatous  condition  of  the  eyeball.  The  presence  of 
venous  pulsation  was  supposed  to  indicate  a  fluctuation  in  the  intra- 
ocular pressui'e,  but  according  to  Memorsky*  this  is  not  so.  He  con- 
siders it  to  be  a  visible  expression  of  the  action  of  the  forces  which 
regulate  the  blood-pressure  within  the  eye. 

The  physiological  excavation  may  be  known  by  its  being  limited  to 
the  central  portion  of  the  disc,  it  is,  moreover,  generally  very  small  and 
shallow,  and  may  continue  throughout  life  without  undergoing  any 
change.  Sometimes  the  excavation  is  well  marked  and  easily  recog- 
nisable, the  central  portion  of  the  disc  presenting  a  peculiar  white, 
glistening  appearance,  of  varying  size  and  form.  This  central,  glistening 
spot  may  be  oval,  circular,  or  longitudinal,  and  its  size  is  generally  very 
inconsiderable  in  comparison  with  that  of  the  disc  ;  it  is  surrounded  by 
a  reddish  zone,  which  may  be  almost  of  the  same  colour  as  the  back- 
ground of  the  eye.  The  width  of  this  zone  varies  with  the  extent  of 
the  excavation ;  if  the  latter  is  small,  the  zone  will  be  very  considerable, 
but  if  it  is  large,  the  zone  will  be  narrow,  and  limited  to  the  periphery 
of  the  disc.  The  edges  of  the  cup  are  generally  slightly  sloping,  and 
never  abrupt  or  steep,  so  that  the  excavation  passes  over  gradually  into 
the  darker  zone  without  there  being  any  sharply-defined  margin.  But 
if  the  excavation  is  conical  or  fann el- shaped  the  edges  are  more  abrupt, 
and  the  margin  more  defined.  On  tracing  the  retinal  vessels  from  the 
periphery  towards  the  centre  of  the  disc,  we  notice  that  they  undergo 
peculiar  changes  when  they  arrive  at  the  margin  of  the  excavation,  for 
instead  of  passing  straight  on,  they  describe  a  more  or  less  acute 
curve  as  they  dip  down  into  it.  This  curve  may  be  very  slight  and 
gradual  if  the  cup  is  shallow,  but  if  it  is  deep  and  extensive  the  curve 
may  be  abrupt  and  give  rise  to  a  displacement  of  the  vessels  at  its  edge. 
In  the  expanse  of  the  excavation,  the  vessels  generally  assume  a  slightly 
darker  shade,  but  they  sometimes  appear  of  a  lighter  and  more  rosy 
tint,  and  seem  to  be  enveloped  by  a  delicate  veil.  The  excavation  is 
frequently  not  in  the  centre  of  the  disc,  but  nearer  its  outer  side.  A 
"  A.  f.  O.,"  xi,  2,  107. 


310  THE  USE   OF   THE  OPHTHALMOSCOPE. 

very  peculiar  appearance  is  produced  if  a  glaucomatous  excavation  occurs 
in  a  nerve  having  a  physiological  cup,  for  then  the  two  conditions  may 
for  a  time  exist  side  by  side  ;  the  physiological  excavation  is,  however, 
subsequently  merged  in  the  deeper  glaucomatous  cup. 

9.— THE  OPHTHALMOSCOPIC  EXAMINATION  OF  DISEASED 

EYES. 

The  Refracting  Media. 

Before  commencing  any  ophthalmoscopic  examination  of  the  fundus, 
the  refracting  media  should  always  be  examined  by  the  oblique  illu- 
mination and  by  transmitted  light  (vide  p.  304).  By  making  this  a 
constant  rule  the  beginner  will  avoid  falling  into  many  an  error  in 
diagnosis  which  might  otherwise  occur,  such  as  mistaking  opacities  of 
the  cornea,  the  capsule,  or  the  lens  for  some  deeper-seated  lesion.  In 
making  an  examination  of  the  lens  or  the  vitreous  humour  the  pupil 
should  be  widely  dilated,  although  an  expert  observer  will  often  be  able, 
even  with  an  undilated  pupil,  to  detect  opacities  which  are  situated  at 
the  margin  of  the  lens,  or  the  periphery  of  the  vitreous  humour,  by 
making  the  patient  look  very  far  in  the  opposite  direction,  which  will 
enable  the  surgeon  to  look  quite  behind  the  iris.  The  colour  of  opacities 
in  the  refracting  media  will  vary  according  to  the  amount  of  illumina- 
tion, and  the  fact  whether  they  are  examined  by  reflected  or  transmitted 
light.  In  the  former  case,  they  will  appear  in  their  true  colours,  the 
fundus  being  in  the  shade,  so  that  they  will  look  like  grey  or  whitish 
opacities  situated  upon  a  dark  background.  It  is  different,  however, 
when  the  fundus  is  lighted  up  with  the  ophthalmoscope,  for  then  the 
opacities  will  appear  like  dark  specks,  of  varying  size  and  form,  upon 
a  bright  red  background,  for  their  surfaces  can  reflect  but  little  light, 
and  they  are  thus  seen  in  shadow.  On  this  account  very  small 
opacities  are  best  seen  by  a  weak  illumination,  for  in  consequence  of 
their  very  slight  reflection,  they  become  invisible  if  the  illumination 
is  too  bright.  It  is  of  much  importance  to  be  able  rightly  to  estimate 
the  depth  at  which  any  opacity  in  the  refracting  media  is  situated. 
There  cannot  be  the  slightest  difficulty  about  tliis  when  the  opacity  is 
in  the  cornea,  the  capsule,  or  the  anterior  portion  of  the  lens,  for  with 
the  oblique  illumination  we  shall  be  able  to  ascertain  the  position  of  the 
opacity  in  relation  to  the  pupil.  Indeed,  for  opacities  in  the  anterior 
half  of  the  eyeball  the  obhque  illumination  is  of  most  service,  but  for 
those  in  the  posterior  half  the  ophthalmoscope  should  be  used.  But  it 
is  best  to  avail  ourselves  of  both  modes  of  examination.  When  the 
opacity  is  situated  in  the  vitreoiis  humour,  it  is  more  difficult  to  ascer- 
tain its  exact  depth.     The  two  following  methods  of  examination  will, 


OPHTHALMOSCOPIC   EXAMINATION   OF   DISEASED  EYES.        311 

however,  enable  us  to  decide  this  : — If,  for  instance,  the  observer  (in 
the  direct  image)  looks  in  such  a  direction  that  his  optic  line  passes 
through  the  tui^ning  point  of  the  patient's  eye,  it  will  be  found  tliat 
this  point  and  the  corneal  reflection  of  the  mirror  will  alone  remain 
stationary  when  the  eye  is  moved  in  diff'erent  directions.  Any  opacity 
which  is  situated  in  front  of  this  point  will  move  in  the  same  direction 
as  the  cornea,  whereas  any  opacity  situated  behind  the  turning  point 
will  move  in  a  direction  opposite  to  that  of  the  cornea.  The  further 
the  opacity  is  n-om  the  turning  point  of  the  eye,  the  greater  will  its 
excursion  be.  Now  the  turning  point  corresponds  as  nearly  as  possible 
to  the  posterior  pole  of  the  crystalHne  lens.  If  there  should  conse- 
quently be  an  opacity  situated  at  this  spot  (posterior  polar  cataract),  it 
wiU  remain  stationary  during  the  various  movements  of  the  eye.  if 
the  opacity  is  situated  in  front  of  the  posterior  pole  it  will  move  in  the 
same  direction  as  the  cornea,  if  the  latter  moves  upwards  the  opacity 
will  do  the  same ;  the  reverse  will  occur  if  the  opacity  is  situated 
behind  the  tui'ning  point,  for  then  it  will  move  downwards  as  the  cornea 
moves  up,  and  vice  versa. 

It  is  more  difficult  to  determine  the  exact  position  of  the  object 
when  it  lies  very  close  to  the  retina.  This  is  best  done  by  the  surgeon 
making  a  slight  movement  with  the  object  lens  (in  the  examination 
with  the  reverse  image),  his  own  and  the  patient's  eye  being  at  the 
same  time  kept  stationary.  The  nearer  that  the  object  is  to  the  observer, 
the  more  raarked  will  be  its  movement  in  the  same  direction  as  the  lens. 
To  illustrate  this  Liebreich*  cites  the  following  example  : — If  we  sup- 
pose that  a  filiform  opacity  were  to  extend  from  the  posterior  pole  of 
the  lens  to  the  centre  of  the  retina,  it  would  appear  like  a  point  when 
seen  from  in  front.  If  we  were  then  to  move  the  convex  lens  from 
right  to  left,  the  anterior  extremity  of  the  opacity  would  pass  to  the 
corresponding  side,  in  front  of  its  posterior  extremity,  so  that  the 
opacity  would  no  longer  appear  like  a  point,  but  a  line.  The  depth  of 
opacities  in  the  vitreous  is,  however,  best  determined  by  the  aid  of  the 
binocular  ophthalmoscope. 

Opacities  of  the  cornea  are  best  seen  with  the  oblique  illumination, 
and  appear  like  small  grey  or  white  spots,  and  their  situation  and 
extent  can  thus  be  ascertained  with  the  greatest  nicety.  This  method 
of  examination  will  also  be  found  useful  in  the  detection  and  removal 
of  foreigTi  bodies  from  the  cornea.  In  the  direct  mode  of  examination 
with  the  ophthalmoscope,  small  opacities  or  facets  in  the  coniea  lend  a 
peculiar  mottled  or  marbled  appearance  to  the  fundus,  as  if  little  dark 
spots  or  streaks  were  studded  over  its  red  expanse.  We  may  thus  also 
readily  detect  changes  in  the  curvature  of  the  cornea,  and  diagnose  the 

*  Frencli  Translation  of  Mackenzie's  "Treatise  on  the  Diseases  of  the  Eye,"  p.  31. 


312  THE  USE   OF   THE   OPHTHALMOSCOPE. 

earliest  stage  of  conical  cornea,  for  the  conical  portion  yields  a  bright 
reflection,  Hke  a  transparent  bead  or  drop  of  water,  with  its  base  half 
in  shadow,  the  situation  of  the  latter  varying  with  the  movements  of 
the  mirror. 

The  appearances  presented  by  different  forms  of  cataract,  etc.,  both 
by  reflected  and  transmitted  light,  have  already  been  described  at 
length  in  the  chapter  upon  the  diseases  of  the  lens. 


Chapter  VII. 
DISEASES   OF  THE   VITREOUS   HUMOUR 


1.— INFLAMMATION   OF   THE   VITREOUS   HUMOUR.— 

HTALITIS. 

It  was  formerly  supposed  that  the  vitreous  humour  was  incapable  of 
undergoing  inflammation,  on  account  of  the  absence  of  nerves  and  blood- 
vessels in  its  structure.  Thanks,  however,  to  the  researches  of  Virchow 
and  "Weber,  it  has  been  proved  beyond  doubt  that  the  vitreous  humour 
can  become  inflamed.  Although  these  inflammatory  changes  generally 
either  accompany  or  supervene  upon  inflammation  of  the  deeper  tunics 
of  the  eyeball,  viz.,  the  retina  and  choroid,  yet  idiopathic  hyalitis  may 
occur,  and  it  may  be  quite  impossible  to  trace  any  participation  of  the 
other  tunics  of  the  eye. 

These  inflammatory  changes  consist  chiefly  in  a  proliferation  or 
hyperplasia  of  the  cells  of  the  vitreous  humour,  which  become  opaque 
and  granular,  and  undergo,  perhaps,  fatty  degeneration.  Sometimes, 
there  is  a  considerable  development  of  connective  tissue  elements,  or 
there  may  be  a  great  tendency  to  suppuration,  and  large  quantities  of 
pus  cells  be  formed. 

The  progress  of  hyalitis  is  best  studied  by  watching  what  changes 
occur  when  a  foreign  body  (e.^.,  a  piece  of  gun  cap,  steel,  etc.,  or  a  dis- 
placed lens)  is  lodged  in  the  vitreous  humour.  If  the  refracting  media 
are  sufficiently  clear  to  permit  of  an  ophthalmoscopic  examination,  we 
find  that  soon  after  the  accident,  the  vitreous  humour  in  the  vicinity  of 
the  foreign  body  loses  its  transparency,  and  becomes  somewhat  hazy, 
which  is  due  to  the  proliferation  of  the  vitreous  cells,  and  an  increase 
of  their  nuclei  and  molecular  contents.  The  foreign  body  appears  to  be 
enveloped  in  a  thin  mist  or  cloud  of  a  bluish-grey  tint,  which  assumes 
a  more  dense  and  firm  appearance  if  much  connective  tissue  is  developed, 
and  a  creamy  yellow  colour  if  suppuration  sets  in.  The  track  of  the 
foreign  body  is  often  visible  in  the  form  of  a  thin  whitish-grey  opacity, 
like  a  thread,  running  towards  it.  We  sometimes  find  that  these 
inflammatory  changes  in  the  vitreous  humom*,  consequent  upon  the 
lodgement  of  a  foreign  body  within  it,  are  idiopathic,  no  trace  of  inflam- 


314  DISEASES   OF   THE   VITREOUS   HUMOUR. 

mation  of  the  other  structures  of  the  eye  being  visible,  either  externally 
or  with  the  ophthalmoscope.  Generally,  however,  this  is  not  the  case, 
for  symptoms  of  ii'ido-cyclitis  or  choroiditis  soon  supervene,  and  the 
eye  is  but  too  frequently  lost  through  suppuration. 

The  simple  (non- suppurative)  form  of  hyalitis  may  be  either  acute 
or  chronic,  and  the  opacity  of  the  vitreous  be  either  diffuse  or  circum- 
scribed. On  ophthalmoscopic  examination,  we  may  find  the  whole 
vitreous  humour  diffusely  clouded,  which  renders  the  details  of  the 
fundus  either  completely  invisible,  or  very  indistinct,  so  that  they 
appear  to  be  covered  by  a  thin  grey  film  or  veil.  In  this  diffuse  opacity 
may  be  noticed  dark,  thread-Hke  films,  of  varying  size  and  shape,  which 
may  be  either  fixed,  or  float  about  when  the  eye  is  quickly  moved. 
Neoplastic  formations  of  connective  tissue  are  often  met  with  at  the 
anterior  portion  of  the  vitreous  humour,  close  to  the  posterior  pole  of 
the  lens.  They  give  i-ise  to  a  more  or  less  extensive  opacity,  which  is 
sometimes  termed  posterior  polar  cataract.  But  connective  tissue  is  also 
formed  in  other  portions  of  the  vitreous  humour,  often  in  very  consider- 
able quantities,  giving  rise  to  membranous  and  filamentous  opacities, 
which,  traversing  the  vitreous  in  different  directions,  may  perhaps  even 
divide  it  into  fibrillar  compartments.  The  true  cellular  gelatinous  sub- 
stance of  the  vitreous  humour  disappears  in  proportion  to  the  develop- 
ment of  the  connective  tissue,  and  generally  becomes  fluid  (synchysis). 
In  such  cases  the  retina  is  often  found  to  be  extensively  detached,  and 
the  vitreous  humour  shrivelled  up  to  a  very  small  space  ;  and  chiefly 
consisting  of  connective  tissue,  of  an  almost  tendinous  structure,  inter- 
spersed with  loculi  containing  cells  which  have  undergone  various 
changes,  and  not  unfrequently  pigment  molecules. 

Although  simple  hyahtis  sometimes  occurs  idiopathically,  yet  gene- 
rally it  is  dependent  upon  an  inflammation  of  the  retina,  choroid,  or 
ciliaiy  body. 

Still  more  so  is  this  the  case  in  the  suppurative  form  of  hyalitis,  which 
is  but  seldom  idiopathic,  being  mostly  associated  with  purulent  irido- 
cyclitis or  irido-choroiditis,  which  supervenes  perhaps  upon  operations 
for  cataract,  injuries,  etc.  As  the  cornea  is  but  too  frequently  opaque, 
or  the  pupil  blocked  up  with  lymph,  it  is  often  impossible  to  trace  the 
course  of  the  disease  with  the  ophthalmoscope.  If  we  are,  however, 
able  to  do  so,  we  sometimes  find  that  the  anterior  portion  of  the 
vitreous  humour,  close  to  the  lens,  yields  a  yellow,  creamy  reflex,  which 
may  be  very  well  seen  with  the  oblique  illumination.  It  is  called 
posterior  hypopyon,  and  is  due  to  pus  in  the  anterior  portion  of  the 
vitreous,  which  may  have  made  its  way  from  the  ciliary  body  or 
anterior  segment  of  choroid,  having  burst  through  the  retina.  In 
such  a  case,  the  other  portions  of  the  vitreous  may  be  found  com- 
paratively, or  even  completely  healthy.  In  other  instances,  the  suppura- 


OPACITIES   OF   THE  VITREOUS   HUMOUR.  31. '5 

tion  occurs  at  the  posterior  or  lateral  portions  of  the  vitreous,  to 
which  it  may  remain  chiefly  confined,  but  it  may  also  become  general, 
and  involve  the  -whole  of  the  vitreous  humour.  Ophthalmitis  generally 
ensues,  and  the  globe  gradually  becomes  atrophied  with  or  without 
previous  perforation  of  the  cornea  or  sclerotic. 

The  prognosis  of  inflammation  of  the  vitreous  humour  will  depend 
chiefly  upon  the  cause,  and  the  extent  to  which  the  deeper  tissues  of 
the  eye  are  implicated.  I  must  therefore  refer  the  reader  for  a  con- 
sideration of  these  points,  as  well  as  the  question  of  ti'eatment,  to  the 
diseases  of  the  choroid  and  retina.  With  regard  to  the  treatment,  I 
may,  however,  state  that  in  the  acute  cases  of  diffuse  hyalitis,  much 
benefit  is  often  experienced  from  sahvation,  and  the  periodic  apjjlication 
of  the  artificial  leech  to  the  temple. 


2.— OPACITIES  OF  THE  VITREOUS  HUMOUR. 

The  presence  of  opacities  in  the  \'itreous  humour  is  easily  detected 
with  the  ophthalmoscope  in  the  direct  mode  of  examination.  The 
patient  should  be  ordered  to  move  his  eye  quickly  and  repeatedly  in 
various  directions,  and  then  to  hold  it  still.  These  movements  will 
cause  the  opacities  to  be  shaken  up,  and  they  will  float  about  in  the  field 
of  vision,  and  we  shall  thus  be  enabled  to  judge  of  their  size  and  density, 
and  to  distinguish  between  the  fixed  and  moveable  ones.  When  the 
eye  is  held  still,  the  latter  soon  sink  again  to  the  lower  portion  of  the 
vitreous.  The  excursions  which  these  opacities  make  are  often  very 
considerable,  and  allow  us  to  estimate  approximately  the  degree  of 
fluidity  of  the  vitreous.  The  binocular  ophthalmoscope  is  particularly 
useful  in  the  examination  of  vitreous  opacities,  and  in  determining  the 
different  depths  at  which  they  are  situated. 

We  have  seen  that  in  simple  hyahtis  the  opacity  of  the  vitreous 
assumes  a  diffuse  grey  appearance,  shrouding  the  whole  fundus  in  a  fine 
veil,  the  sight  being  at  the  same  time  greatly  affected.  Sometimes  the 
opacity  is  chiefly  confined  to  one  portion,  perhaps  the  central,  in  which 
case  the  yellow  spot  and  the  retina  in  its  vicinity  will  appear  hazy, 
whilst  the  details  at  the  periphery  of  the  fundus  can  be  clearly  seen. 
This  partial,  uniform  opacity  may  shift  somewhat  when  the  eye  is  moved. 
A  peculiarly  dangerous  form  of  diffuse  opacity  of  the  vitreous  is  that 
which  occurs  suddenly,  and  after  clearing  somewhat,  recurs  perhaps 
several  times,  for  it  is  but  too  often  followed  by  detachment  of  the 
retina.  We  must  not,  however,  confound  with  this,  the  temporary 
cloudiness  of  the  vitreous  which  occurs  in  glaucoma,  and  which  is  due 
to  a  serous  hypersed'etion,  evidently  dependent  upon  irritation  of  the 
ciliary  nerves. 


310  DISEASES   OF   THE  VITREOUS   HUMOUR. 

Together  with  a  more  or  less  diflfuse  opacity,  we  often  meet  with 
various  circular,  membranous,  or  filiform  opacities,  which  are  due  to 
the  remains  of  blood  eflfusions,  or  alterations  in  the  cells  of  the  vitreous 
humour,  which  may  have  undergone  fatty,  purulent,  or  pigmentary 
changes  ;  or  connective  tissue  elements  may  have  been  formed.  These 
opacities  assume  very  various  shapes  and  forms.  At  first,  perhaps,  the 
patient  only  notices  a  dark  speck  before  his  eyes,  which  he  cannot  wipe 
away ;  then  thin,  flaky  membranes  may  appear,  which  float  about  and 
assume  difierent  forms  and  positions  with  every  movement  of  the  eye. 
Between  these  opacities,  the  field  of  vision  may  either  appear  clear  or  be 
more  or  less  diffusely  clouded.  The  nearer  the  opacities  are  to  the 
retina  the  more  will  they  throw  a  shadow  upon  it.  If  they  are  some 
distance  frora  it,  they  may  not  throw  individual  shadows,  but  only  give 
rise  to  a  general  dimness  of  vision.  The  patients,  as  Von  Graefe  has 
pointed  out,  often  throw  their  eyes  periodically  upwards  in  reading,  etc., 
in  order  to  cause  the  opacities  to  move  and  shift  their  position,  so 
that  the  field  of  vision  may  be  momentarily  cleared,  which  of  course 
enables  them  to  see  more  distinctly.  This  periodic  upward  movement 
of  the  eye  is  accompanied  by  an  elevation  of  the  upper  lid,  and  gives  a 
peculiar  and  characteristic  appearance  to  the  patient. 

With  the  ophthalmoscope,  we  can  readily  distinguish  these  opaci- 
ties as  dark,  fixed,  or  floating  bodies,  assuming  various  shapes,  like  dark 
spots,  threads,  or  reticulated  fibrillfe ;  sometimes,  however,  they  are  so 
delicately  fine  that  we  cannot  individualize  them,  and  the  whole  fundus 
only  appears  to  be  hazy  and  veiled. 

The  disease  in  which  opacities  of  the  vitreous  are  by  far  most  fre- 
quently met  with  is  sclerotico- choroiditis  posterior.  The  posterior 
portion  of  the  vitreous  frequently  becomes  fluid,  and  the  opacities  may 
be  seen  floating  very  freely  about  in  it.  Sometimes,  however,  the 
synchysis  extends  to  the  greater  portion  or  even  the  whole  of  the 
vitreous  humour. 

Extravasation  of  blood  into  the  vitreous  humour  is  a  very  frequent 
cause  of  these  opacities.  The  haemorrhage  is  generally  due  to  a  rupture 
of  some  of  the  vessels  of  the  choroid,  more  especially  at  its  anterior 
portion,  where  it  is  most  vascular,  and  at  which  situation  the  retina 
is  thinnest,  and  therefore  most  readily  gives  way ;  whereas,  when  the 
efiusion  takes  place  in  the  posterior  portion  of  the  choroid,  it  is  more 
prone  to  cause  detachment  of  the  retina  than  to  perforate  the  latter  and 
make  its  way  into  the  vitreous.  This  is  due  to  the  fact  that  the  con- 
nection between  the  choroid  and  retina  is  at  this  point  very  lax,  and  the 
retina  thicker  than  in  the  region  of  the  ora  serrata.  Hence  a  more  or 
less  considerable  detachment  of  the  retina  is  generally  produced  at  the 
posterior  portion  of  the  fundus,  before  perforation  takes  place.  When 
the  blood  has  become  absorbed,  and  the  vitreous  is  again  transparent, 


OPACITIES   OF   THE   VITREOUS   HUMOUR.  317 

we  can  always  discover  changes  in  the  choroid,  such  as  ecchynioses, 
etc.,  showing  whence  the  haemorrhage  has  proceeded,  and  we  are  also 
sometimes  able  to  detect  a  cicatrix  in  the  retina,  where  the  latter  has 
been  ruptured  by  the  extravasation  of  blood.  Schweigger*  has  pointed 
out  that  hfemorrhage  into  the  vitreous  humour  occurs  far  more  fre- 
quently from  the  choroidal  vessels  than  from  those  of  the  retina,  for  the 
latter  are  not  only  smaller  in  size,  but,  on  account  of  the  peculiar 
arrangement  of  the  connective  tissue  fibrillEe  (Stiitzfasern)  of  the  retina, 
and  the  resistance  offered  by  the  membrana  limitans  interna,  hjemorrhage 
from  the  retina  extends  generally  towards  the  choroid,  and  not  into  the 
vitreous. 

We  are  generally  able,  with  the  ophthalmoscope,  easily  to  distinguish 
extravasations  of  blood  into  the  vitreous,  as  they  yield  a  peculiar  bright 
red  reflex.  But  if  the  haemorrhage  is  very  extensive  anddifiuse,  it  may 
not  be  possible  to  light  up  the  eye  at  all,  the  fundus  looking  quite  dark, 
and  not  affording  the  least  reflex.  The  sight  is  generally  very  greatly 
and  very  suddenly  impaired,  the  patient  having  the  sensation  as  if  there 
was  a  dense  red  mist  or  veil  before  his  eye.  Wlien  the  blood  is  begin- 
ning to  be  absorbed,  fixed  and  floating  opacities  of  a  filiform,  reticulated, 
or  membranous  character  make  their  appearance,  and  become  rolled 
Tip  into  dark  fantastically-shaped  masses  when  the  eye  is  moved.  Some- 
times when  the  absorption  has  gone  on  for  some  time,  and  the  vitreous 
has  regained  much  of  its  transparency,  a  fresh  extravasation  takes  place, 
and  this  may  recur  several  times.  Although  the  patient  may  regain  a 
considerable  am.ount  of  sight  during  these  intervals,  the  recurrence  of 
hsemorrhage  is  always  to  be  regarded  with  great  anxiety,  as  it  but  too 
frequently  leads  to  detachment  of  the  retina,  glaucomatous  complications, 
or  atrophy  of  the  eyeball. 

When  the  hfemorrhage  has  been  at  all  considerable,  permanent 
opacities  are  generally  left  behind,  and  may  produce  great  impairment 
of  vision,  and  even  detachment  of  the  retina  by  traction.  H.  Miillerf 
was  the  first  to  show  that  the  latter  is  a  not  unfrequent  consequence  of 
opacities  in  the  vitreous. 

Extravasations  of  blood  into  the  vitreous  humour  are  very  often  of 
traumatic  origin,  being  produced,  for  instance,  by  severe  blows  upon 
the  eye,  causing  a  rupture  of  the  blood-vessels  of  the  choroid  or  retina. 
They  may,  however,  arise  independently  of  this,  if  there  is  much  con- 
gestion of  the  internal  tunics  of  the  eyeball,  or  if  the  coats  of  the  vessels 
are  diseased. 

In  the  treatment  of  opacities  of  the  vitreous  humour,  we  must 
be  especially  guided  by  the  cause,  and  whether  they  are  due  to,  and  a 
part  symptom  of,  inflammatory  afiectious  of  the  deeper  tunics  of  the  eye- 

*  "  Archiv.  fiir  Ophtlialmologie,"  vi,  2,  259. 
t  Ibid.,  iv,  1,  372. 


ol8  DISEASES   OF   THE   VITREOUS   HUMOUR. 

ball,  or,  perhaps,  to  intra-ocular  hoemorrliages  caused  by  rupture  of 
sorae  of  the  choroidal  vessels.  In  the  former  case,  our  attention  must 
be  chiefly  dii-ected  to  the  treatment  of  the  primary  disease.  The 
absorption  of  the  vitreous  opacities  may,  however,  be  greatly  aided 
by  preventing  all  congestion  of  the  choroidal  or  retinal  vessels  by  the 
application  of  the  artificial  leech.  I  have  often  gained  great  benefit 
from  its  use,  as  it  facihtates  and  hastens  the  absorption,  and  relieves 
the  intra-ocular  blood-vessels.  If  the  patient  is  weak  and  anaemic,  I 
generally  prefer  dry  cupping  at  the  temple,  making  use  only  of  the  glass 
cylinder  of  the  Heurteloup.  This  may  be  repeated  once  or  twice  a 
week,  according  to  circumstances.  But  if  the  patient  is  strong  and 
plethoric,  I  invariably  take  away  blood  by  means  of  the  artificial  leech, 
one  cylinder  full  being  the  usual  quantity.  In  those  cases  in  which  the 
afiection  of  the  vitreous  is  dependent  upon  derangement  of  the  func- 
tions of  the  uterus  or  liver,  the  general  health  must  be  strictly  attended 
to.  Much  benefit  is  experienced  from  the  use  of  saline  mineral  waters, 
as  the  Pulna,  Kissingen,  Kreuznach,  etc.,  and  the  tendency  to  conges- 
tion and  hyperasmia  of  the  vessels  of  the  eye  should  be  reheved  by  hot 
pediluvia  or  hip-baths.  The  absorption  of  blood  into  the  vitreous  may 
also  be  hastened  by  the  application  of  a  firm  compress  bandage.  In 
cases  of  dense  membranous  opacities  of  the  vitreous  which  had  resisted 
all  efforts  of  absorption,  Von  Graefe  has  derived  much  benefit  from 
tearing  them  through  with  a  fine  needle.*  This  produces  not  only  an 
improvement  in  the  sight,  but  renders  the  opacities  more  amenable  to 
treatment,  and  prevents  their  exercising  any  deleterious  influence  upon 
the  retina  by  traction. 

It  is  of  much  practical  importance  to  distinguish  between  the  patho- 
logical opacities  of  the  vitreous  humour  and  the  subjective  physiological 
muscae  volitantes  (Myodesojnct)  which  are  met  with  in  perfectly  healthy 
eyes.  These  assume  the  most  various  shapes  and  appearances.  Some- 
times they  look  like  small  transparent  discs  or  circles,  Avhicli  may  be 
isolated  or  arranged  in  groups  ;  or  they  may  resemble  strings  of  bright 
beads,  or  filamentous  bands,  which  float  about  in  all  directions  through 
the  field  of  vision.  They  are  generally  due  to  minute  beaded  filaments 
or  groups  of  granules  in  the  vitreous  humour,  and  are  quite  physio- 
logical, occurring  more  or  less  in  all  eyes.  They  are  so  minute  that 
they  arc  perfectly  invisible  with  the  ophthalmoscope,  and  this  instru- 
ment is  therefore  of  the  greatest  use  in  enabling  us  to  distinguish 
between  the  physiological  and  pathological  muscce  volitantes,  for  directly 
it  reveals  to  us  the  presence  of  opacities  in  the  -sdtreous,  however  slight 
tliey  may  be,  we  must  regard  them  as  pathological  products.  I  must, 
however,  mention  in  passing,  that  certain  changes  in  the  choroid  and 

*  "  A.  f.  O.,"  ix,  2,  101. 


OPACITIES   OF   THE   VITREOUS   HUMOUR.  319 

retina  may  give  rise  to  fixed  dark  spots  in  the  visual  field  (so-called 
"  scotomata  ").  No  careful  observer  could,  however,  confound  these 
with  the  opacities  in  question. 

Musca)  become  yevy  evident  when  the  person  regards  some  light 
and  highly  illuminated  object,  as,  for  instance,  the  bright  clear  sky, 
a  very  white  wall,  or  the  brightly  illuminated  field  of  the  microscope, 
whereas,  in  a  siibdued  light  the  floating  bodies  may  be  hardly,  if  at  all 
observable.  They  are  also  increased  by  fatigue  of  the  eye  from  over- 
work, or  when  the  retina  is  very  sensitive  and  irritable ;  the  same  often 
occurs  if  there  is  any  derangement  of  the  nervous  system  or  of  the 
digestive  organs.  The  situation  of  the  muscaa  may  be  approximately 
ascertained,  as  was  shown  by  Listing,  by  making  the  patient  look 
through  one  of  the  minute  apertures  of  the  steuopaic  apparatus,  or  a 
pin-hole  in  a  card.  Now,  if  the  card  is  moved  in  a  certain  direction 
(e.g.,  upwards),  and  the  objects  also  move  upwards,  they  are  situated 
behind  the  pupil,  whereas,  if  they  move  in  the  opjsosite  direction,  they 
lie  in  front  of  the  pupil.  The  greater  the  degree  of  movement,  the 
further  does  the  object  lie  from  the  pupil.*  The  position  of  the  objects 
can  be  estimated  with  still  greater  accuracy  by  Donders's  mode  of 
examination  a  double  vue.  He  employs  a  diaphragm  pierced  by  two 
small  apertures,  situated  about  one  line  from  each  other,  so  that  two 
shadows  are  thrown  upon  the  retina,  and  cover  one  another  by  nearly 
one  half.t  We  must  distinguish  the  muscEe  which  have  their  seat  in 
the  vitreous  humour  from  the  appearances  produced  by  eyelashes,  maco- 
lachrymal  drops  on  the  conjunctiva  and  cornea,  and  the  radii  and  spots 
situated  in  the  lens.  For  full  information  upon  this  interesting  subject 
of  Entoptics,  I  would  refer  the  reader  to  Dr.  Jago's  admirable  and 
exhaustive  treatise.;}; 

Short-sighted  persons  are  especially  troubled  by  muscse,  for  even 
the  physiological  motes  are  rendered  peculiarly  marked  and  distinct 
by  the  size  of  the  circles  of  diffusion  upon  the  retina.  In  consequence 
of  this,  they  often  prove  a  source  of  the  greatest  anxiety  and  trouble  to 
the  patient.  Already,  perhaps,  in  constant  dread  that  his  myopia  should 
rapidly  increase,  and  lead  eventually  to  great  impairment  of  vision,  or 
even  total  blindness,  the  appearance  of  these  muscse  often  frightens  him 
greatly,  and  causes  him  to  yield  undivided  attention  to  his  eye  sight, 
and  to  watch  every  symptom  with  anxiety.  This  is  more  particularly 
the  case  with  those  persons  who  are  dependent  upon  their  sight  for 
their  livelihood,  or  are  naturally  of  a  nervous  and  anxious  temperament. 
Even  although  we  may  earnestly  and  repeatedly  assure  them  that  these 

*  Helmholtz  Phjsiologische  Optik.,  150. 

t  Donders's  "  Anomalies  of  Accommodation  and  Refraction,"  201. 
X  "  Entoptics,  with  its  use  in  Physiology  and  Medicine,"  by  James  Jago,  M.D 
1864  (ChurchiU). 


320  DISEASES   OF   THE  VITREOUS   HUMOUR. 

physiological  motes  are  not  of  the  slightest  importance,  and  are  a  source 
of  no  danger,  we  but  too  frequently  fail  to  alleviate  their  mental  dis- 
tress. They  seek  advice  from  others  who,  in  their  opinion,  are  more 
competent,  and  willing  to  understand  the  nature  of  their  complaint. 
Amongst  such  patients  the  charlatan  finds  his  most  fervid  and  profit- 
able followers.  I  have  met  with  several  most  distressing  cases  in  which 
advertising  quacks  have  greatly  frightened  patients  who  complained 
of  these  motes,  assuring  them  that  they  depended  upon  some  secret 
disorder,  and  if  not  speedily  and  properly  treated,  that  they  would  lead 
to  amaurosis,  of  which,  indeed,  they  were  the  sure  precursory  symptoms. 
Such  patients  must  be  cheered  up,  and  prevented  as  much  as  possible 
from  thinking  of  their  ailments.  Their  general  health  must  be  strength- 
ened, and  any  irregularities  of  the  circulation  or  digestive  organs 
removed.  Much  benefit  is  often  also  produced  by  the  use  of  dark 
blue  or  neutral  tint  eye-protectors,  as  they  diminish  the  intensity  of  the 
light,  and  thus  render  the  muscse  less  visible. 

It  has  been  already  mentioned,  in  speaking  of  the  opacities  in  the 
vitreous  humour,  that  the  latter  may  lose  its  normal  gelatinous  con- 
sistence, and  become  partially  or  wholly  fluid.  This  condition,  which  is 
termed  syncliysis,  cannot  be  diagnosed  with  certainty  if  there  are  no 
floating  opacities.  An  erroneous  opinion  sometimes  prevails,  that  the  eye 
is  always  soft  in  all  cases  of  fluid  vitreous.  But  this  is  not  the  case,  for 
the  tension  of  the  eyeball  varies  according  to  the  amount  of  the  vitreous 
humour,  and  not  according  to  the  natui'e  of  its  consistence.  Thus  in 
glaucoma,  the  tension  of  the  eyeball  may  be  very  greatly  increased, 
owing  to  the  hyper- secretion  of  the  vitreous  humour,  which  may  be 
perfectly  fluid.  Again,  diminution  of  the  intra-ocular  tension  only 
proves  that  the  contents  of  the  vitreous  are  diminished  in  quantity, 
although  it  must  be  allowed  that  in  such  cases  the  vitreous  is  often 
fluid.  Tremulousness  of  the  iris  is  also  an  uncertain  symptom.  It 
can  exist  only  when  the  iris  has  lost  its  natural  support  from  the 
crystalhne  lens,  either  through  absence  of  the  latter,  or  through  its 
having  become  displaced.  Together  with  fluidity  of  the  vitreous,  the 
diameter  of  the  eyeball  may  have  become  increased,  and  the  position  of 
the  lens  with  regard  to  the  iris  somewhat  altered,  and,  therefore,  on 
account  of  this  loss  of  support,  the  iris  may  be  tremulous.  But  the 
most  reliable  symptom  is  the  presence  of  floating  opacities.  In  staphy- 
lomatous  enlargements  of  the  eyeball,  the  vitreous  is  always  found  more 
or  less  fluid.  The  same  occurs  if  a  foreign  body  or  a  displaced  lens 
has  become  lodged  in  the  vitreous.  Moreover,  when  vitreous  humour 
is  lost,  as  for  instance  during  an  operation  for  cataract,  or  owing  to  a 
wound  of  the  eye,  this  loss  is  always  made  up  by  fluid.  It  is  of 
importance  to  be  aware,  if  possible,  of  the  consistence  of  the  vitreous 
humour  before  undertaking  an  operation  for  cataract,  in  order  that  we 


FOREIGN   BODIES,   ETC.,   IN   THE   VITREOUS   HUMOUR.         321 

may  take  every  precaution  to  limit   as  much  as   possible  the  loss  of 
vitreous  which  must  inevitably  occur. 

A  most  beautiful  and  striking  appearance  is  presented  by  the  pre- 
sence of  crystals  of  cholesterine  in  the  vitreous.  As  this  condition 
generally,  if  not  indeed  always,  occurs  in  a  fluid  state  of  the  vitreous, 
it  has  been  termed  sparkling  synchysis  (synchysis  etincelant).  The  exact 
mode  of  origin  of  these  crystals  is  not  at  present  known,  but  it  seems 
that  they  often  occui*  after  ha3morrhage  into  the  vitreous,  and  are  there- 
fore very  probably  deposited  from  the  blood ;  or  they  may  be  due  to 
fatty  changes  in  the  vitreous  humour.  The  appearance  presented  by 
cholesterine  in  the  vitreous  is  most  characteristic  and  striking,  if  the 
ophthalmoscope  is  used.  On  eveiy  movement  of  the  eye  a  shower  of 
bright,  sparkling  crystals  is  seen  floating  through  the  field  of  vision, 
which  gradually  sink  down  to  its  lower  part  when  the  eye  is  again 
held  still.  Sometimes  the  crystals  float  about  in  an  otherwise  clear 
vitreous,  or  they  may  be  intermixed  with  darker  filamentous  opacities, 
to  which  they  may  even  adhere,  fringing  them  with  a  sparkling  lustrous 
border.  They  have  also  been  met  with  in  the  retina,  and  even  between 
the  retina  and  choroid.  When  they  are  situated  at  the  anterior 
portion  of  the  vitreous,  close  behind  the  lens,  they  may  be  noticed 
even  with  the  oblique  illumination.  Von  Graefe  mentions  a  case  in 
which  they  gradually  disappeared. 

3.— roREiG:Nr  bodies,  etc.,  in  the  vitreous  humour. 

If  a  foreign  body  becomes  lodged  in  the  vitreous  humour,  it  but  too 
frequently  excites  the  most  severe  and  destructive  inflammation  of  the 
tissues  through  which  it  has  passed,  or  with  which  it  lies  in  contact.  Thus 
if  it  has  entered  through  the  cornea,  this  and  the  iris  often  become 
violently  inflamed ;  the  lens,  throiigh  which  the  foreign  body  has  also 
passed,  becomes  cataractous  and  swells  up,  thus  tending  to  increase 
still  more  the  severity  of  the  inflammation.  If  the  injury  has  been 
severe  and  the  foreign  body  lies  in  the  vitreous  humour  close  to  the 
retina,  it  often  excites  in*flammation,  perhaps  of  a  suppurative  character, 
in  this  and  the  choroid,  which  leads  perhaps  to  atrophy  of  the  globe. 
If  the  media  remaixi  sufiiciently  clear  to  permit  of  an  ophthalmoscopic 
examination  of  the  fundus,  we  generally  find  that  for  the  first  few  days 
the  foreign  body  may  be  seen  of  its  natural  colour,  mostly  sunk  down  in 
the  vitreous  humour.  Then,  the  latter  becomes  somewhat  clouded  in 
the  vicinity  of  the  foreign  body,  surrounding  it  with  a  thin,  greyish-blue 
halo,  which,  as  the  plastic  nature  of  the  exudation  increases,  assumes  a 
denser  and  more  opaque  yellowish- white  appearance,  hiding  the  foreign 
body  from  view.     It  has  in  fact  become  encysted.     At  the  same  time 

Y 


322  DISEASES   OF   THE   VITREOUS   HUMOUR. 

the  vitreous  humour  is  often  more  or  less  diffusely  clouded,  and  dark, 
filamentous  opacities  float  about  in  it.  When  it  regains  sufficient 
transparency  to  permit  of  an  ophthalmoscopic  examination  of  the 
fundus,  we  not  unfrequently  find  that  a  detachment  of  the  retina  has 
occurred  (perhaps  to  a  considerable  extent),  and  that  a  more  or  less 
extensive  inflammation  of  the  choroid  has  taken  place.  In  some  rare 
instances,  however,  the  course  may  be  more  favourable ;  so  that 
although  the  injury  may  be  followed  by  severe  inflammation,  the  foreign 
body  becomes  encysted  in  the  vitreous  humour,  which  gradually  regains 
its  transparency  as  the  inflammatory  symptoms  subside,  and  finally  the 
sight  may  be  restored  to  its  normal  condition,  the  foreign  body  lying 
innocuous  in  the  vitreous  humour.  Such  instances  are,  however,  very 
rare,  and  can  only  occur  when  the  foreign  body  is  but  small.  The  fol- 
lowing is  a  brief  outline  of  such  a  case,  which  came  under  my  care  at 
the  Middlesex  Hospital  in  1862.* 

"  Samuel  P ,  aged  20,  was  wounded  in  the  left  eye  by  a  chip  of 

iron  flying  off  a  hammer.  This  was  followed  by  severe  inflammatory 
symptoms,  great  swelling  of  the  lids,  lachrymation,  photophobia,  ii'itis. 
At  the  outer  and  upper  side  of  the  iris,  quite  close  to  the  periphery, 
there  was  a  small  triangular  opening,  showing  the  passage  of  the 
foreign  body,  and,  corresponding  to  it,  there  was  a  small  cicatrix  in  the 
cornea.  On  his  admission  into  the  hospital  (about  a  week  after  the 
accident)  he  could  only  count  fingers  up  to  a  distance  of  7  or  8  feet. 
The  tension  of  the  eye  was  then,  and  remained  throughout,  normal. 
When  the  inflammatory  symptoms  had  greatly  subsided,  a  short  oph- 
thalmoscopic examination  was  made,  and  it  was  found  that  the  vitreous 
humour  was  clouded,  with  a  few  filamentous  opacities  floating  about 
in  it.  The  condition  of  the  eye  was  soon  so  much  improved  that  the 
patient  could  read  JSTo.  1  of  Jiiger,  and  No.  19  at  18  feet;  the  lens  was 
clear,  the  vitreous  slightly  hazy,  yet  permitting  the  optic  disc  to  be 
seen  distinctly.  At  the  outer  and  lower  portion  of  the  vitreous  was 
seen  a  white,  opalescent,  oval  mass,  the  encysted  foreign  body,  whose 
passage  through  the  vitreous  could  be  traced  by  a  faint  bluish  line 
running  towards  it.  A  local,  circumscribed  inflammation  in  the 
choroid  had  occurred  in  its  vicinity,  and  small  portions  of  choroidal 
pigment  were  agglomerated  around  and  beneath  the  foreign  body.  I 
saw  the  patient  occasionally  for  some  years  after  the  accident ;  the  last 
time  was  about  two  years  ago  (in  1865),  and  the  eye  was  then  in 
precisely  the  same  condition,  and  he  could  use  it  perfectly." 

I  must  mention,  however,  that   even  after  a  foreign   body  has  lain 
encysted  and  dormant  for  many  years  in  the  vitreous  humour,  it  may 
give  rise  to  severe  inflammatory  symptoms  which  may  lead  to  atrophy 
of  the  globe,  or  awaken  sympathetic  ophthalmia. 
*  Vide  "  Laucet,"  Aug.  23,  1862. 


FOREIGN  BODIES,   ETC.,   IN   THE  VITREOUS    HUMOUR.         323 

The  treatment  must  be  cliiefly  directed  to  subduing  the  inflamma- 
tion. Coki  compresses  should  be  applied  to  the  eye,  and  perhaps  leeches 
to  the  temple.  The  pupil  must  be  kept  widely  dilated  by  atropine.  If 
suppurative  iritis  or  irido-cyclitis  is  set  up,  it  may  be  necessary  to  put 
the  patient  rapidly  under  the  influence  of  mercury.  Or,  if  there  is  a 
considerable  hypopyon,  repeated  paracentesis,  or  a  large  iridectomy 
may  be  indicated.  The  latter  should  never  be  neglected  if  the  tension 
of  the  eye  is  increased. 

With  regard  to  removal  of  the  cataractous  lens,  or  of  the  eyeball, 
from  its  setting  up  sympathetic  irritation  or  inflammation,  I  must 
refer  the  reader  to  the  chapters  upon  "Traumatic  Cataract"  and  "Sym- 
pathetic Ophthalmia."  The  question  may  arise  as  to  the  advisability 
of  removing  a  foreign  body  in  the  vitreous  humour,  and  we  must  be 
principally  guided  in  deciding  this  by  its  position  and  nature.  Interest- 
ing cases  of  this  kind  have  been  reported  by  Dixon  (R.  L.  0.  H.  Rep., 
No.  6)  and  Critchctt  (Lancet,  1854). 

Although  cysti'cerci  have  been  met  "with  in  various  parts  of  the  eye, 
as  the  cornea,  anterior  chamber,  iris,  and  lens,  as  well  as  in  the  orbit, 
their  most  frequent  seat  appears  to  be  in  the  background  of  the  eye. 
Thus  Von  Graefe*  states  that  amongst  80,000  patients  he  has  found  a 
cysticercus  in  the  deeper  tissues  of  the  eye  in  rather  more  than  80  cases, 
in  the  anterior  chamber  three  times,  beneath  the  conjunctiva  five  times, 
in  the  lens  once,  and  in  the  orbit  once.  The  youngest  individual  was 
nine  years  old ;  about  90  per  cent,  of  the  cases  occurred  between  the 
ages  of  15  and  55,  and  nearly  two-thirds  of  the  cases  were  met  with  ia 
men.  In  England  the  disease  would  seem  to  be  very  rare.  I  have 
only  met  with  one  case  of  cysticercus  in  the  vitreous  diagnosed  with 
the  ophthalmoscope,  which  occurred  in  a  soldier  who  was  sent  to  me 
for  examination  by  Professor  Longmore.  If  the  membrane  which 
envelopes  the  cysticercus  in  the  vitreous  humour  is  not  too  dense,  the 
entozoon  presents  a  very  pecuhar  and  characteristic  appearance.  Its 
original  seat  appears  generally  to  be  beneath  the  retina,  and  it  is  only 
at  a  later  stage  of  its  existence  that  it  perforates  the  latter  (with  its 
head  first)  and  makes  its  way  into  the  vitreous  humour.  Sometimes 
it  carries  the  retina  with  it,  and  thus  produces  an  extensive  detachment, 
by  which  it  is  covered.  In  other  cases,  it  tears  through  the  retina  and 
lies  fi:ee  in  the  vitreous  humour.  Here  it  frequently  becomes  encysted, 
being  surrounded  by  a  more  or  less  dense  membrane,  which  may  pre- 
vent the  recognition  of  the  real  nature  of  the  affection.  If  this  is  not 
the  case,  but  the  entozoon  is  without  an  investing  membrane,  it  pre- 
sents the  appearance  of  a  pale  greyish-blue,  or  greenish-blue  vesicle, 
somewhat  cii'cular  or  flask-shaped,  with  a  short  neck  and  round  head, 
*  "  A.  f.  O.,"  xU,  2,  174. 

T   2 


324  DISEASES   OF   THE   VITREOUS   HUMOUR. 

on  which  the  suckers  may  be  seen.  If  the  animal  is  alive,  we  may  by 
closely  watching  it,  observe  distinct  undulating,  tremulous  movements 
of  its  outline,  the  head  being  perhaps  alternately  stretched  out  from, 
or  drawn  into  the  receptaculum.  The  position  of  the  latter,  in  which 
the  head  and  neck  lie  when  they  are  retracted,  is  indicated  by  a  small 
white  spot  at  one  point  of  the  vesicle.  The  slightest  movement  of  the 
head  causes  a  gentle  quivering  motion  of  the  vesicle,  and  on  bright 
illumination  of  its  surface  we  notice,  especially  near  the  margin,  a 
peculiar  bright  iridescence,  the  play  of  colours  constantly  changing, 
but  having  a  decidedly  red  tint.  All  these  m.inuti£e  are  more  easily  dis- 
tinguished when  the  cysticercus  lies  free  in  the  vitreous  humour,  than 
when  it  is  covered  by  the  retina.  If,  in  the  latter  case,  its  movements 
are  very  marked  and  considerable,  the  super-jacent  retina  may  also 
undergo  a  distinct  tremulous  motion.  Von  Graefe  has  been  able  in 
four  cases  to  watch  the  development  of  the  entozoon  from  the  very 
commencement.  At  the  outset,  there  appeared  a  delicate  greyish-blue 
opacity  at  some  portion  of  the  fundus,  situated  evidently  in  the  retina 
or  between  the  latter  and  the  choroid.  In  the  course  of  three  or  four 
weeks,  the  little  cysticercus  vesicle  escaped,  in  two  cases,  from  the  most 
prominent  portion  of  the  opacity  into  the  vitreous  humour.  In  the 
two  other  cases,  the  outline  of  the  vesicle  became  gradually  more  and 
m.ore  apparent  from  beneath  the  opacity,  and  was  distinctly  situated 
beneath  the  retina,  the  latter  lying  either  in  tense  and  close  apposition 
to  the  entozoon,  or  being  separated  by  an  effusion  of  subretinal  fluid,  in 
which  case  there  exists  a  greater  mobility  of  the  vesicle.  The  latter 
gradually  glides  along  further  and  further  beneath  the  retina,  until  at 
last,  after  perhaps  several  months  have  elapsed,  it  breaks  through  into 
the  vitreous  humour.  The  original  position  of  the  cysticercus  beneath 
the  retina  is  indicated  by  the  faintly  recognisable  remains  of  a  small 
greyish- white  spot,  from  which  can  be  traced  a  distinct  greyish  track, 
if  the  animal  has  made  its  w:ay  for  some  distance  beneath  the  retina 
before  perforation.  Although  opacities  of  the  vitreous  may  appear 
at  the  commencement,  this  is  not  the  rule,  but  at  a  later  period  the 
"vitreous  generally  becomes  clouded,  and  the  eye  is  finally  lost  from  slow 
and  insidious  choroiditis.  Generally  this  occurs  within  two  years  of 
the  outset  of  the  disease. 

The  presence  of  a  cysticercus  being  so  extremely  dangerous  to  the 
eye.  Von  Graefe*  was  led  to  attempt  its  extraction.  By  so  doing,  it 
may  be  possible  to  retain  a  certain  degree  of  vision,  to  preserve  the 
shape  of  the  eyeball,  or  at  the  worst,  to  diminish  the  pain  and  pro- 
tracted course  of  the  atrophy  of  the  eyeball.  In  Von  Graefe's  first  case, 
he  made  a  large  iridectomy  downwards  and  inwards,  so  as  thoroughly 
to  expose  the  exact  position  of  the  entozoon.  Subsequently  he  passed 
*  "  A.  f.  O.,"  iii,  2,  320. 


FOREIGN   BODIES,   ETC.,   IN   THE   VITREOUS  HUMOUR.         325 

a  couching  needle  through  the  sclerotic,  about  one  and  a-half  or  two 
lines  further  back  than  the  point  where  the  needle  would  be  inserted  for 
the  operation  of  couching.  Through  this  opening  he  then  passed  the 
point  of  the  closed  canula  forceps,  and  pushed  it  forward  until  it 
became  visible  between  the  pos^fior  surface  of  the  lens  and  the 
vesicle,  along  which  he  pushed  it,  until  the  instrument  had  reached  the 
neck  of  the  entozoon,  the  branches  wex^e  then  opened,  the  neck  seized, 
and  the  animal  slowly  drawn  towards  the  incision.  When  the  latter 
had,  however,  been  reached,  the  animal  escaped,  and  the  forceps  had  to 
be  again  passed  in,  when  the  entozoon  was  successfully  extracted ;  the 
vesicle  was,  however,  torn.  The  irritation  produced  by  the  operation 
caused,  however,  an  increase  in  the  vitreous  opacities,  and  some  months 
later  the  lens  became  clouded.  In  another  case,*  upon  which  Von  Graefe 
operated,  he  endeavoured  to  exti-act  the  parasite  without  rupture  of 
the  vesicle.  A  large  iridectomy  was  made  downwards  and  outwards, 
opposite  the  cysticercas,  and  followed,  a  month  later,  by  extraction 
of  the  transparent  lens  by  the  lower  flap  operation,  a  further  portion 
of  the  iris  being  at  the  same  time  excised.  Six  weeks  later,  the 
cysticercus  was  extracted  through  a  linear  incision  in  the  cornea.  The 
operation  was  followed  by  an  increase  in  the  vitreous  opacities,  but  these 
were  subsequently  almost  entii'ely  absorbed. 

In  Plate  V,  fig.  9,  will  be  found  an  excellent  illustration  of  the 
appearances  presented  by  a  cysticercus  in  the  vitreous.  Liebreich  says, 
in  explanation  of  this  plate,  "  The  parasite,  which  was  originally 
developed  beneath  the  retina,  and  then,  after  perforating  it,  penetrated 
into  the  vitreous  humom-,  could  be  seen  with  such  perfect  distinctness, 
that  the  undulating  movements  and  coarctations  of  the  vesicle  could 
not  only  be  observed  at  its  outline,  but  also  at  the  posterior  wall,  which 
could  be  distinguished  through  the  anterior  wall.  This  was  especially 
the  case  towards  the  centre,  where,  as  the  red  tint  in  the  illustration 
shows,  more  light  can  shine  through  than  at  the  margin,  on  which  the 
light  falls  more  obliquely,  and  consequently  sufiers  greater  reflection. 
The  neck,  especially  at  its  junction  with  the  vesicle,  is  of  an  opaquer 
tint,  and  studded  with  minute  white  dots  (chalky  particles).  This 
more  opaque  portion,  where  the  neck  joins  the  vesicle,  is  also  the  most 
fii-m,  and  we  must  endeavour  to  seize  it  here,  if  we  wish  to  extract  the 
animal.  In  a  case  upon  which  I  operated  last  winter,  I  succeeded  in 
seizing  it  at  this  point  with  the  canula  forceps,  introduced  through  the 
sclerotic.  By  means  of  an  ophthalmoscope,  which  was  fixed  to  the 
forehead,  I  illuminated  the  animal  and  the  instrument,  so  that  I  could 
see  them  accm-ately.  In  the  illustration  we  recognise  at  the  head  two 
suckers  (the  other  two  being  placed  posteriorly),  and  the  buccal  extre- 
mity which  is  directed  upwards.  The  shape  of  the  head  did  not  always 
*  "A.  f.  0.,"iv,  2,  171. 


326  DISEASES  OF   THE  VITREOUS   HUMOUR. 

present  the  appearance  depicted  in  the  illustration,  but  varied  in  a  very 
remarkable  manner," 

In  rare  instances,  the  formation  of  new  blood-vessels  in  the  vitreous 
may  be  observed  with  the  ophthalmoscope.  Thus  Becker*  saw  new 
vessels  formed  upon  the  anterior  surface  of  an  abscess  in  the  vitreous 
humour,  and  again  in  purulent  infiltration  of  the  vitreous  ;  in  the  latter 
case,  the  vessels  were  situated  close  behind  the  lens,  and  were  distin- 
guishable with  the  naked  eye.  Becker,t  moreover,  narrates  an  extra- 
ordinary case  of  an  independent  neo-plastic  formation,  in  which  the 
connection  between  the  newly-formed  vessels  of  the  growth  and  those 
of  the  retina  could  be  distinctly  traced. 

4.— PERSISTENT  HYALOID  ARTERY. 

The  hyaloid  artery  generally  shrivels  up  and  disappears  during  the 
later  period  of  foetal  life.  In  some  rare  instances,  however,  remains  of 
it  in  the  vitreous  humour  have  been  subsequently  traced  with  the 
ophthalmoscope,  either  in  the  form  of  a  short,  dark  stripe,  or  of  a  dark 
thread  running  through  the  vitreous  humour  from  the  optic  disc 
towards  the  posterior  portion  of  the  lens.  If  the  vessel  is  still  patent 
and  carries  blood,  as  was  noticed  by  Zehender,J  it  appears  like  a  red 
cord  by  incident  light ;  which  in  this  case  underwent  considerable  undu- 
lations when  the  eye  was  moved,  the  vitreous  humour  being  evidently 
fluid.  Liebreich§  records  a  case  in  which  there  existed  a  physiological 
cup  of  the  optic  nerve  together  with  the  persistent  hyaloid  artery,  and 
the  latter  could  be  distinctly  traced  up  to  its  point  of  origin  from  the 
central  artery  of  the  retina. 

*  "  Bericlit  iiber  die  Wiener  Augeuklinik,"  114.  f  Ibid.,  106. 

X  "Kl.  Monatsbl.,"  1863,  259.  §  Ibid.,  349. 


Chapter  VIII. 
DISEASES    OF    THE    RETINA. 


1.— HYPEREMIA  OF  THE  RETINA. 

We  may  distinguish  two  forms  of  hyperaemia  of  the  retina,  viz. : 
the  arterial  or  active,  and  the  venous  or  passive.  The  former  is 
generally  acute,  and  is  characterised  by  the  patient  experiencing  some 
symptoms  of  ii-ritability  in  the  eye,  such  as  photophobia,  lachrymation, 
subconjunctival  redness,  and  an  inability  to  continue  for  any  length  of 
time  any  work  which  necessitates  a  strong  effort  of  the  accommodation. 
There  are  often  also  subjective  symptoms  of  an  irritable  state  of  the 
retina,  such  as  flashes  of  light,  etc.  On  examining  the  eye  with  the 
ophthalmoscope,  we  find  that  the  optic  disc  is  abnormally  red  and 
flushed,  on  account  of  the  increased  injection  of  the  capillary  twigs 
upon  its  surface.  If  this  increased  vascularity  is  very  pronounced  at 
the  margin  of  the  disc,  its  outhne  becomes  somewhat  ill-defined  from  its 
similarity  in  tint  to  the  surrounding  fundus.  The  size  of  the  arteries 
may  be  slightly  increased,  and  the  smaller  branches  are  more  numerous 
and  apparent,  which  is  especially  observable  in  the  region  of  the  yellow 
spot.  The  retinal  veins  are  also  somewhat  dilated.  According  to 
Stellwag,  more  or  less  considerable  portions  of  the  fundus  are  rendered 
almost  uniformly  red  by  a  very  delicate  and  close-meshed  network  of 
vessels.  It  must  always  be  remembered,  that  the  degree  of  vascularity 
of  the  retina  and  optic  disc  varies  much  in  different  individuals,  and  in 
persons  of  different  complexions.  Thus,  it  is  less  marked  in  pale  and 
anaemic  individuals  than  in  the  florid  and  plethoric.  If  only  one  eye  is 
affected,  the  appearances  presented  by  it  should  always  be  compared 
with  those  of  the  other  eye,  as  this  will  enable  us  more  accurately  to 
estimate  the  degree  of  vascularity  of  the  retina,  and  guard  us  against 
an  error  in  diagnosis. 

Arterial  hyperoBmia  of  the  retina  is  generally  dependent  upon  causes 
which  excite  an  increased  vascularity  of  the  eye,  thus,  it  may  be  artifi- 
cially produced  by  the  application  of  a  drop  of  some  astringent 
collyrium  to  the  conjtmctiva.  It  is  often  due  to  prolonged  exposure  to 
very  bright  light,  more  especially  if  the  eyes  are  at  the  same  time 


328  DISEASES   OF   THE  RETINA. 

employed  in  some  small  and  delicate  work,  as  for  instance  in  micro- 
scopizing,  engraving,  watcL- making,  etc.,  by  artificial  light.  It  is  also 
frequently  met  with  in  hypermetropic  persons  who  work  or  read  much 
without  the  assistance  of  glasses. 

In  the  venous  or  passive  form  of  hypersemia,  we  notice  that  the 
retinal  veins  are  abnormally  lai'ge,  dark,  and  perhaps  tortuous,  which  is 
especially  marked  in  the  smaller  veinlets,  which  may  present  a  some- 
what corkscrewy  appearance.  There  is  also  either  a  spontaneous  or  a 
very  easily  producible  venous  pulsation.  If  the  venous  congestion  has 
lasted  some  length  of  time,  we  frequently  notice  a  slightly  oedematous 
condition  of  the  retina  around  the  optic  disc,  or  along  the  course  of  some 
of  the  larger  vessels,  which  appear  to  be  fringed  by  a  delicate  greyish- 
blue  opacity  or  halo.  Care  must  be  taken,  not  to  mistake  this  for  another 
form  of  opacity  along  the  edge  of  the  vessels  which  is  due  to  hyper- 
trophy of  their  coats,  and  which  will  be  noticed  hereafter.  The  sight 
after  a  time  generally  becomes  somewhat  impaired,  but  this  disappears 
again  when  the  cause  is  removed.  This  form  of  hyperEemia  is  mostly 
slow  in  its  development,  and  is  due  to  a  state  of  venous  congestion 
dependent  perhaps  upon  some  disturbance  in  the  general  circulation, 
caused  by  an  affection  of  the  heart  or  liver ;  or  again,  it  may  be  depen- 
dent upon  local  causes  which,  by  impeding  the  efflux  of  blood  from  the 
retinal  veins,  give  rise  to  a  mechanical  venous  hypersemia.  Amongst 
such  causes  we  may  instance  intra-cranial  tumours  which  press  upon 
the  cavernous  sinus,  or  tumours  situated  in  the  orbit  and  compressing 
the  optic  nerves  ;  or  again,  an  increase  in  the  intra-ocular  tension  (a 
glaucomatous  condition  of  the  eye).  I  must  here  point  out  that  it  is 
quite  erroneous  to  assert,  that  the  tension  of  the  globe  is  more  or  less 
increased  in  the  passive  or  venous  hypersemia  of  the  retina.  This  is 
in  fact  mistaking  cause  and  effect,  and  such  a  mistake  is  apt  to  lead  to 
great  errors  in  diagnosis  and  treatment.  The  intra-ocular  tension  is 
never  increased  when  the  venous  retinal  hypereemia  is  simply  due  to 
disturbance  in  the  general  circulation,  to  tumours  pressing  upon  the 
cavernous  veins,  or  to  intra-orbital  tumours  ;  it  is  only  increased  in  a 
glaucomatous  condition  of  the  eye,  and  here  the  venous  hyperasmia  is 
due  to  the  augmented  tension  of  the  globe,  and  does  not  produce  it. 

If  the  arterial  hypersemia  of  the  retina  is  considerable,  the  patient 
should  not  be  allowed  to  use  his  eyes  at  all,  more  especially  by  artificial 
light,  until  the  symptoms  have  quite  subsided.  If  the  affection  is  due 
to  some  defect  in  the  accommodation  or  refraction  of  the  eye,  as  for 
instance  presbyopia  or  hypermetropia,  this  must  be  corrected  by  suitable 
glasses.  Blue  or  smoke-coloured  eye-protectors  should  be  worn  to 
guard  the  eyes  against  the  irritating  influence  of  bright  sun  or  artificial 
light,  and  the  eye-douche  will  be  found  beneficial  in  relieving  the 
irritability  of  the  eye.      In  the  treatment  of  venous  hypersemia  our 


IDIOPATHIC   RETINITIS.  329 

attention  must  be  chiefly  directed  towards  the  prevention  of  any  dis- 
turbance and  congestion  of  the  venous  system.  The  functions  of  the 
heart,  liver,  and  uterus  must  be  regulated,  and  special  care  be  taken  to 
prevent  determination  of  blood  to  the  head.  Much  benefit  is  often 
derived  from  hot  stimulating  foot-baths  and  a  course  of  mildly  purgative 
mineral  waters.  The  congestion  of  the  retinal  circulation  is  best 
relieved  by  Heurteloup's  artificial  leech.  It  should  be  applied  periodi- 
cally, at  intervals  of  six  or  seven  days,  and  if  the  patient  is  anasmic  or 
in  feeble  health,  but  little  blood  (^  or  f  of  a  cylinder)  should  be  taken, 
or  dry  cupping  should  be  substituted. 

2.— INFLi3IMATI0N  OF  THE  RETINA. 

Before  I  pass  on  to  the  description  of  the  different  forms  of  retinitis 
wlaich  gain  their  distinctive  characters  either  from  the  anatomical 
changes  which  accompany  them,  or  from  the  constitutional  affections 
which  have  given  rise  to  them,  it  will  be  well  to  consider  the  various 
symptoms,  ophthalmoscopic  and  anatomical,  which  are  more  or  less 
common  to  all  forms  of  inflammation  of  the  retina,  and  which  may  be 
very  well  grouped  under  the  head  of  "  idiojjathic  retmitis." 

Idiopathic  Retinitis. 

Practically  we  may  divide  this  into  two  principal  forms.  In  the 
one,  the  pathological  changes  are  chiefly  those  of  osdema  of  the  retina  or 
of  a  serous  infiltration  of  its  connective  tissue  ;  in  the  other,  the  inflam- 
matory changes  afiect  the  proper  structure  or  parenchyma  of  the  retina. 
We  may,  therefore,  distinguish  a  serous  and  a  jxirenchijmatous  form  of 
idiopathic  retinitis.  The  former  is  generally  acute,  the  latter  more 
chronic  in  its  course. 

As  the  serous  retinitis  does  not  give  rise  to  striking  ophthalmoscopic 
symptoms,  it  is  not  always  easy  to  diagnose  this  disease  if  the  effusion 
is  but  slight.  This  is  especially  the  case  if  a  strong  illumination  is 
_  employed,  for  these  deHcate  changes  in  the  retina  are  best  observed  by 
a  moderate  degi'ee  of  illumination,  and  in  the  erect  image.  Serous 
retinitis  is  characterised  by  the  appearance  of  a  very  delicate,  bluish 
grey  or  bluish-green  veil,  which  is  spread  over  the  surface  of  the  I'etina, 
and  hides  the  epitheHum  and  vessels  of  the  choroid.  The  opacity, 
which  may  affect  a  more  or  less  considerable  portion  of  the  retina,  is 
quite  uniform,  and  presents  no  marked  strige,  dots,  or  patches.  It  is 
only  with  a  very  weak  illumination  and  a  considerable  magnifying 
power  that  we  can  observe  a  faint  striation  of  the  opacity.     Mauthner* 

*  "  Lehrbuch  der  Ophthalmoscopic,"  301. 


330  DISEASES   OF   THE   RETINA. 

mentions  two  cases  in  which  the  retinitis  presented  very  pecuHar 
greenish  striae.  This  was,  however,  only  observable  by  a  weak  illnmi- 
nation,  and  in  the  direct  mode  of  examination.  The  opacity  shades  off 
towards  the  periphery,  gradually  and  imperceptibly,  into  the  transparent 
normal  retina,  which  not  unfrequently  remains  quite  unaffected.  The 
serous  infiltration  is  especially  marked  in  the  vicinity  of  the  optic  disc, 
but  gradually  diminishes  in  intensity  towards  the  region  of  the  yellow 
spot,  on  account  of  the  decrease  in  the  thickness  of  the  retina  at  this 
point.  Hence  the  choroid  also  shines  through  more  distinctly  here,  and 
thus  lends  a  redder  tint  to  the  macula  lutea.  Indeed  this  redness  is  some- 
times so  very  striking,  more  especially  on  account  of  its 'contrast  with 
the  neighbouring  greyish  opacity  of  the  retina,  that  it  might  be  readily 
mistaken  for  an  effusion  of  blood.  The  periphery  of  the  retina  is  often 
quite  free  from  seroxis  infiltration,  and  the  details  of  the  choroid  can 
then  be  plainly  distinguished  at  this  point.  The  optic  disc  is  always 
somewhat  swollen  and  cedematous,  and  its  outline  indistinct  and  ill 
defined,  the  choroidal  and  sclerotic  margins  being  rendered  unapparent 
by  the  serous  infiltration.  The  retinal  arteries  generally  show  but  little 
alteration  in  their  appearance,  being,  perhaps,  only  slightly  veiled,  and 
a  little  attenuated.  The  veins,  on  the  other  hand,  are  strikingly  hyper- 
oemic ;  they  are  large,  dark,  tortuous,  the  latter  being  especially  marked 
in  the  smaller  branches.  On  close  examination  we  may  often  notice  that 
the  vessels  do  not  throughout  their  whole  course,  lie  always  on  the  same 
level,  but  here  and  there  dip  a  little  into  the  effusion,  or  are  pushed  a 
little  outwards  (towards  the  vitreous)  by  it.  In  the  former  case,  they 
will  seem  slightly  indistinct  and  veiled,  in  the  latter,  the  portion  which 
is  nearest  to  the  observer  will  appear  peculiarly  dark  and  visible.  These 
peculiarities  are  best  distinguished  with  the  binocular  ophthalmoscope, 
or  in  the  erect  image.  There  are  also  sometimes  small  extravasations 
of  blood  on  or  beside  the  vessels.  The  sight  is  always  much  affected, 
sometimes  so  considerably  that  the  patient  cannot  distinguish  the 
largest  letters,  or  count  fingers.  The  field  of  vision  is  also  contracted, 
but  if  the  peripheral  portion  of  the  retina  is  unaffected,  the  correspond- 
ing portion  of  the  field  will  not  be  impaired.  The  first  complaint  of  the 
patient  is,  generally,  that  he  notices  a  grey  film  or  veil  before  his  eyes, 
which  gradually  increases  in  thickness  and  surrounds  the  various  objects, 
hiding  them  more  and  more  from  the  sight,  until  he  becomes  almost 
totally  blind.  With  all  this,  the  external  appearance  of  the  eye  remains 
normal  and  healthy,  excepting  that  the  pupil  generally  becomes  sluggish 
and  somewhat  dilated,  but  even  this  is  not  always  very  marked,  and  might 
be  easily  overlooked.  There  is  no  marked  photophobia,  lachrymation, 
ciliary  injection,  or  intense  pain,  none  of  the  symptoms,  in  short,  which 
are  still  so  often  erroneously  described  as  characteristic  of  inflammation 
of  the  retina,  but  which  are  not  due  to  retinitis,  but  to  hypersesthesia  of 


IDIOPATHIC   RETINITIS.  331 

the  retina — two  perfectly  different  affections.  We  shall  see  hereafter,  to 
what  grave  errors  in  treatment  a  diagnosis  of  retinitis  from  these 
symptoms  but  too  frequently  leads.  It  must  be  particularly  remem- 
bered, that  in  serous  retinitis  the  ophthalmoscopic  symptoms  are  never 
so  marked  and  striking  as  might  be  expected  from  the  great  impairment 
of  sight,  the  latter  being  probably  chiefly  due  to  the  compression  of  the 
nerve  elements  by  the  serous  effusion. 

The  prognosis  should  always  be  very  guarded,  because  if  the  affec- 
tion lasts  for  some  time,  the  nerve  elements  of  the  retina  may  become 
atrophied,  and  the  sight  be  permanently  destroyed.  Or  again,  this  form 
may  pass  over  into  a  more  chronic  inflammation,  affecting  chiefly  the 
parenchyma  of  the  retuia,  and  giving  rise,  pei'haps,  to  diseases  of  the 
choroid  or  the  vitreous  humour.  The  danger  of  detachment  of  the 
retina  must  also  be  borne  in  mind. 

The  treatment  should  be  chiefly  directed  towards  relieving  the  con- 
gestion of  the  retinal  vessels,  and  for  this  purpose  local  depletion  by 
means  of  the  artificial  leech  will  be  found  most  efficacious.  The  free 
action  of  the  kidneys  and  skin  should  be  maintained  by  sahne  diuretics 
and  diapharetics.  A  pair  of  dark  blue  glasses  should  be  worn  so  as  to 
protect  the  eyes  against  all  glare  and  bright  light.  All  employment  of 
the  eyes  must  be  forbidden  until  they  have  quite  recovered. 

In  the  parenchymatous  retinitis,  the  changes  are  not  confined 
to  a  serous  infiltration  of  the  connective  tissue,  but  this  and  the 
nervous  elements  of  the  retina  undergo  other  inflammatory  changes, 
such  as  proliferation  of  the  cells,  hypertrophy,  sclerosis,  and  fatty 
or  colloid  degeneration.  The  sclerosis  of  the  connective  tissue  may, 
according  to  Iwanoff,*  be  chiefly  confined  to  the  membrana  limitans 
interna,  or  affect  the  basic  connective  tissue  which  pervades  the 
retina  in  a  vertical  direction,  and  supports  the  other  elements  like 
a  framework.  On  account  of  these  various  changes,  the  ophthal- 
moscopic appearances  are  far  more  marked  and  striking  than  in 
the  serous  retinitis.  The  optic  disc  is  opaque,  swollen,  somewhat 
hypersemic,  and  of  a  reddish  grey  colour ;  its  outline  is  irregular 
and  indistinct,  passing  insensibly  over  into  the  retina,  without  any 
clear  line  of  demarcation.  The  swelling  is  due  to  serous  infiltration  or 
inflammatory  exudation,  which  may  have  extended  from  the  retina  to 
the  optic  nerve,  or  vice  versa.  If  the  effusion  is  serous  in  character,  the 
opacity  will  be  of  a  pale,  greyish  pink,  or  fawn  colour  ;  but  where  there 
is  much  exudation  of  lymph,  it  will  be  more  opaque,  white,  and  perhaps 
somewhat  glistening.  If  the  exudation  occupies  the  more  external 
layers  of  the  retina,  the  vessels  may  be  observed  to  pass  distinctly  over 
it  without  any  dipping  ;  whereas,  if  it  is  situated  in  the  inner  layers  of 

*  Vide  IwanofF's  very  interesting    papers  on  Retinitis,  in  the  "  Kl.  Monats- 
blatter,"  1864,  415,  and  also  in  the  "  Archiv.  f.  Ophthalmologic,"  xi,  1,  136. 


332  DISEASES  OP   THE  RETINA. 

the  retina,  or  quite  on  tlie  surface  of  the  disc,  the  vessels  will  be  more 
or  less  interrupted  and  hidden  by  it.  The  retinal  arteries  are  sometimes 
but  slightly  changed  in  appearance,  in  other  cases  they  are  more  or  less 
diminished  in  size,  and  rendered  indistinct  by  the  exudations.  The  veins 
are  increased  in  size,  darker  in  colour,  and  their  tortuosity  is  generally 
very  marked. 

Blood  extravasations  of  varying  size  and  extent,  are  strewn  about  on 
and  around  the  blood-vessels  in  different  portions  of  the  retina,  as  well 
on  the  optic  disc  and  its  vicinity.  If  these  extravasations  are  situated  in 
the  inner  portion  of  the  retina,  they  will  present  a  peculiar  striped 
or  striated  appearance,  their  edges  being  irregular ;  which  is  due  to  the 
radiating  course  of  the  optic  nerve  fibres,  between  which  the  blood  is 
effused.  If  the  haemorrhages  occupy  the  more  external  layers  of  the  retina, 
the  effusions  will  be  round,  and  have  a  smooth  uniform  appearance  quite 
free  from  stride.  The  exudations  into  the  retina  also  vary  much  in  size 
and  appearance.  Sometimes,  they  look  like  small  white  or  greyish- white 
dots  strewn  about  singly  or  in  small  clusters.  In  other  cases,  they  are 
larger,  and  form  well  marked  white  patches  or  flakes,  of  considerable 
size,  the  edges  of  which  are  perhaps  fringed  by  the  smaller  dots.  The 
colour  of  these  exudations  varies  from  a  greyish  white  to  a  creamy  tint, 
and  they  often  have  a  peculiar  glistening  appearance,  which  is  due  to 
their  containing  fatty  elements.  They  are  met  with  in  different  parts 
of  the  retina,  but  especially  in  and  around  the  optic  disc,  and  in  the 
region  of  the  yellow  spot. 

Although  I  have  used  the  term  exudation  for  these  patches  in  the 
retina,  I  must  state  that  this  is  not  always  quite  correct  in  the  strict 
acceptation  of  the  term,  for  they  are  often  due  to  inflammatory  changes 
in  the  connective  tissue  or  nerve  elements  of  the  retina,  giving  rise  to 
a  proliferation  of  the  cells  and  their  contents,  or  they  are  caused  by  a 
degenerative  metamorphosis  of  a  fatty  or  colloid  nature.  But  as  it  is 
difficult,  and  often  quite  impossible,  to  distinguish  ophthalmoscopically 
between  these  different  products,  and  as  the  term  exudation  has  been 
generally  accepted,  I  have  thought  it  best  to  retain  it. 

When  the  exudations  are  situated  in  the  external  portion  of  the 
retina  (in  which  case,  they  are  generally  due  to  proliferation  of  the  cells, 
and  fatty  or  colloid  degeneration  of  the  external  granular  layer  with 
sclerosis  of  the  membrana  limitans  externa,  the  bacillar  layer  becoming 
subsequently  affected),  we  find  that  they  afford  the  appearance  of  smooth 
greyish- white  or  cream-coloured,  perhaps  glistening  patches,  which  do 
not  show  a  striated  arrangement,  and  are  evidently  situated  beneath  the 
retinal  vessels,  for  the  latter  pass  over  them  without  dipping  into  them, 
or  being  interrupted  or  veiled  in  their  course.  We  may  at  the  same 
time  often  notice  that  the  choroid  in  the  vicinity  of  the  exudations 
is  undergoing  certain  inflammatory  changes,  which  consist  chiefly  in  a 


IDIOPATHIC   RETINITIS.  333 

thinning  of  the  epithelium  and  an  absorption  of  its  pigment,  so  that  the 
choroidal  vessels  become  more  apparent.  The  stroma  of  the  choroid 
also  becomes  affected,  and  it  is  now  no  longer  a  case  of  simple  retinitis, 
but  of  choroido-retinitis.  When  the  retinal  exudations  subsequently- 
become  absorbed,  we  find  that  extensive  changes  in  the  choroid  have 
taken  place  beneath  them.  In  such  cases  the  inflammation,  although 
apparently  chiefly  affecting  the  retina,  often  commences  in  the  choroid, 
and  extends  thence  to  the  retina. 

The  inflammatory  changes  may,  'however,  be  chiefly  confined  to 
the  inner  portion  of  the  retina,  giving  rise  at  first  to  hypertrophy 
of  the  stroma,  formation  of  nuclei  in  the  layer  of  the  optic  nerve 
fibres,  and  neo-plastic  formations  of  connective  tissue  (Iwanoff)*. 
These  fibres  of  connective  tissue  are  often  arranged  in  bundles,  and  if 
they  increase  very  greatly  in  quantity,  they  may  gradually  compress  and 
destroy  the  nerve  fibres.  The  optic  nerve  fibres  and  ganglion  cells  may 
also  undergo  proliferation  and  sclerosis  of  their  elements,  and  subsequently 
perhaps  fatty  degeneration.  Another  very  interesting  fact  is,  that  in 
this  form  of  retinitis  the  membrana  Hmitans  interna  becomes  thickened, 
and  occasionally  shows,  at  certain  points,  small  excrescences  which 
bulge  into  the  vitreous  humour.  The  latter  is  often  affected,  becoming 
hazy  and  pervaded  by  opacities,  which  are  chiefly  observable  at  its  pos- 
terior portion.  Detachment  of  the  retina  may  also  occur.  This  form 
of  retinitis  is  very  frequently  associated  with  irido-cyclitis  or  irido- 
choroiditis,  and  then  it  generally  commences  at  the  peripheral  portion 
of  the  retina,  near  the  ora  serrata,  and  extends  from  thence  towards 
the  centre.  Wben  these  inflammatory  exudations  are  situated  in  the 
inner  layers  of  the  retina,  we  find  that  they  are  rather  striated  in 
appearance,  and  that  the  retinal  vessels,  instead  of  passing  straight 
and  uninterruptedly  over  them,  are  seen  to  dip  into  them  here  and 
there,  becoming  indistinct  or  even  invisible  at  these  points. 

After  the  disease  has  lasted  for  some  time,  the  exudations  and  hemorr- 
hagic effusions  raay  undergo  absorption,  the  stasis  in  the  circulation  be 
relieved,  the  blood-vessels  assume  a  more  normal  appearance,  and  the 
swelling  and  oedema  in  and  around  the  optic  disc  subside,  so  that  it  regains 
a  more  shai-ply  defined  outline.  The  sight  at  the  same  time  improves 
considerably,  and  this  amelioration  may  become  permanent.  But  the 
disease  does  not  always  run  so  favourable  a  course,  for  the  nerve 
elements  of  the  retina  may  have  suffered  so  considerably  as  to  render 
any  improvement  of  the  sight  impossible.  This  may  be  due  either  to 
the  inflammatory  changes  (sometimes  even  assuming  a  purulent  cha- 
racter) which  they  have  themselves  undergone,  or  to  the  great  hyper- 
trophy and  sclerosis  of  the  connective  tissue,  which  encroaches  more 
and  more  upon  the  nerve  elements,  compresses  them,  and  gradually 
*  "A.  f.  0.,"xi,  1,  139. 


334  DISEASES  OF   THE   RETINA. 

leads  to  atrophy  of  the  retina.  If  the  optic  nerve  has  been  much  impli- 
cated in  the  inflammatory  process,  the  atrophic  changes  may  also 
commence  in  it. 

The  coats  of  the  blood-vessels  often  undergo  sclerosis  and  fatty 
degeneration,  becoming  thickened,  and  the  channel  of  the  vessel  per- 
haps narrowed.  The  blood-vessels  then  assume  the  appearance  of 
whitish  bands,  with  a  small  central  red  streak  of  blood  flowing  through 
them.  As  this  change  in  the  coats  of  the  vessels  may  take  place  to  a 
greater  or  less  extent  in  all  forms  of  retinitis,  I  do  not  think  that  it  is 
desirable  to  make  a  special  form  of  it,  even  in  those  instances  in  which 
it  assumes  a  very  considerable  extent,  affecting  perhaps  nearly  all  the 
retinal  vessels,  as  in  some  rare  and  very  exceptional  cases  recorded 
by  Wecker,*  Nagel,t  and  Iwanoff".  The  latter  has  proposed  to  call  it 
"  Perivascular- retinitis."  In  the  case  mentioned  by  Nagel  all  the 
retinal  arteries  and  their  branches  were  changed  in  both  eyes  into  white 
bands,  which,  on  closer  examination,  were  observed  to  be  pervaded  by  a 
central  red  line  or  blood  current.  Only  very  few  of  the  small  arterial 
twigs  were  of  a  red  colour.  The  veins,  on  the  other  hand,  were  normal 
in  appearance,  although  somewhat  narrow  and  irregular  in  calibre.  At 
the  periphery,  there  were  a  few  fine  veinlets  changed  into  white  bands. 
On  account  of  this  white  appearance  of  the  blood-vessels,  it  might  easily 
be  siipposed  that  they  were  bloodless,  and  the  case  be  mistaken  for  one 
of  embolism  of  the  central  artery  of  the  retina.  The  difference  between 
these  two  conditions  may,  however,  be  best  distinguished,  as  has  been 
shewn  by  Liebreich,  by  attention  to  the  two  following  points : — 1.  If 
the  vessel  is  not  changed  in  its  entire  course,  we  should  commence  the 
ophthalmoscopic  examination  from  a  point  where  it  is  still  red,  and  trace 
from  thence  the  contours  of  the  vessel.  If  it  is  bloodless,  we  can  observe 
the  outline  of  the  vessel  going  on,  and  the  thickness  of  the  latter 
remaining  the  same,  whereas  if  there  is  hypertrophy  of  the  coat  there  is 
an  increase  in  its  thickness.  2.  Another  method  is,  to  throw  a  very  small 
pencil  of  Hght  close  to  the  point  of  the  vessel  which  we  wish  to  examine. 
By  this  means  we  can  illuminate  the  parts  lying  behind  the  vessel,  and 
then,  if  the  latter  is  empty,  it  still  looks  like  a  white  streak,  whereas, 
if  its  coats  are  hypertrophied,  it  will  look  red,  on  account  of  the  column 
of  blood  shining  through. 

Retinitis  is  but  rarely  met  with  as  an  idiopathic  affection,  but  some- 
times it  is  difficult  to  determine  its  exact  cause.  It  is  probable  that  it 
may  be  produced  by  prolonged  exposure  to  extremely  bright  light,  as 
from  a  furnace  or  large  cooking  fire,  or  by  excessive  use  of  the  eyes, 
especially  by  strong  artificial  light.  At  first,  only  a  hypersemic  condition 
of  the  optic  nerve  and  retina  is  noticed,  and  then,  if  the  employment  is 

*  Wecker,  "  Etudes  Opht.lialmologiqucs,"  ii,  323. 
t  "  Xlinisulic  Mouutsblilttcr,"  1SG4.,  394. 


IDIOPATHIC   RETINITIS.  335 

persisted  in,  retinitis  may  ensue.  But  retinitis  is  far  more  frequently 
due  to  some  constitutional  affection,  or  consequent  upon  some  other 
disease  of  the  eye,  e.g.,  choroiditis,  etc.  Thus,  it  may  be  dependent 
upon  irregularities  of  the  general  circulation,  and  is  therefore  sometimes 
m.et  with  in  affections  of  the  heart,  or  in  disturbances  of  the  uterine 
functions,  and  in  the  later  stages  of  pregnancy,  in  which  case,  however, 
albuminuria  is  generally  present.  It  may  also  be  caused  by  syphilis,  by 
certain  affections  of  the  kidney,  especially  Bright' s  disease  and  diabetes, 
and  by  cerebral  diseases.  In  the  latter  case,  it  generally  assumes  the 
form  of  neuro- retinitis. 

The  prognosis  will  chiefly  depend  upon  the  cause  and  severity  of  the 
disease,  and  the  extent  to  which  the  nerve  elements  of  the  retina  are 
implicated  in  the  inflammatory  changes.  We  shall  see,  when  consider- 
ing the  different  special  forms  of  retinitis,  that  the  serous  infiltration  of 
the  retina,  blood  extravasations,  and  fatty  degeneration  of  its  connective 
tissue,  etc.,  may  become  absorbed,  and  excellent  vision  be  restored  as 
long  as  the  optic  nerve  elements  have  not  suffered  much.  For  changes 
in  them  are  not  retrogressive,  and  consequently  the  sight  remains  per- 
manently impaired.  Vision  is  sometimes  not  very  greatly  affected  if 
the  region  of  the  yellow  spot  is  not  implicated  in  the  disease  ;  so  that 
the  patient  may  be  still  able  to  read  tolerably  fine  print.  But  his 
general  impression  of  larger  or  distant  objects  is  mostly  indistinct  and 
hazy,  the  objects  appearing  to  be  shrouded  in  a  mist  or  cloud.  In 
other  cases,  the  impairment  of  sight  is  very  considerable. 

The  field  of  vision  may,  as  far  as  extent  is  concerned,  be  normal, 
but  the  perception  at  the  periphery  is  generally  somewhat  diminished, 
often  indeed  considerably  so ;  there  may  also  be  gaps  in  the  field,  the 
situations  of  which  correspond  to  those  of  the  more  extensive  exudations 
in  the  retina. 

A  peculiar  phenomenon  is  sometimes  observed,  as  consequent  upon 
inflammatory  changes  in  the  regions  of  the  yellow  spot,  either  dependent 
upon  retinitis  or  choroido-retinitis ;  I  mean  micropsia,  so  that  objects 
appear  smaller  to  the  patient  than  they  really  are.  If  he  be  directed 
to  copy  or  trace  a  given  figui*e  (such  as  a  circle  or  quadrant)  he  will 
always  draw  it  considerably  smaller  than  it  is  in  reality.  The  difference 
in  tbe  sizes  of  the  image  of  the  object  in  the  two  eyes  (if  only  one  is 
affected  with  micropsia)  may  also  be  estimated,  as  has  been  suggested 
by  Von  Graefe,  by  holding  a  prism,  with  its  base  downwards,  before 
the  affected  eye ;  this  will  cause  its  retinal  image  to  lie  a  little  below  that 
of  the  other  eye,  and  the  patient  can  thus  easily  estimate  their  relative 
sizes.  This  micropsia  is  evidently  due  to  the  fact,  that  the  position  of 
some  of  the  rods  and  cones  is  deranged  by  the  inflammatory  changes 
in  the  retina.  Besides  the  diminution  in  the  size  of  the  objects, 
the   patients   often   notice  that  horizontal   lines,  instead  of  appearing 


336  DISEASES   OF   THE   RETINA. 

straight,  seem  bent  and  crooked  ;  this  is  termed  "  metamorphopsia,"  * 
and  is  due  to  an  alteration  in  the  position  of  the  rods  and  cones,  which 
may  be  caused  by  the  presence  and  pressure  of  inflammatory  products, 
or  by  shrinking  and  contraction  of  the  retina. 

3.— RETINITIS  ALBUMINURICA  (NEPHRITIC  RETINITIS, 
Plate  III,  Fig.  6). 

As  a  certain  form  of  inflammation  of  the  retina  is  often  met  with 
in  Bright's  disease  of  the  kidney,  and  as  it  presents  some  special  and 
characteristic  symptoms,  it  has  been  designated  "retinitis  albuminu- 
rica."  The  peculiar  grouping  and  localization  of  the  pathological 
changes  in  the  retma  are  so  marked  and  constant  in  this  form  of 
retinitis,  that,  as  has  been  more  especially  pointed  out  by  Liebreich,  the 
presence  of  Bright's  disease  may  be  diagnosed  with  certainty  by  means 
of  the  ophthalmoscope  alone.  At  the  outset  of  the  disease  this  is  not, 
however,  the  case,  for  then  the  appearances  do  not  yet  afibrd  any 
special  characteristics.  The  afiection  commences  with  a  fulness  in  the 
retinal  veins,  which  are  dilated,  darker  in  colour,  and  more  or  less 
tortuous  ;  whereas  the  arteries  are  either  normal  in  appearance  or  but 
slightly  narrowed  in  calibre.  The  optic  disc  is  hypersemic,  and  this  is 
soon  followed  by  a  faint,  bluish-grey,  serous  infiltration  of  the  optic 
nerve  and  the  retina  in  its  vicinity.  The  outline  of  the  disc  then 
becomes  somewhat  veiled  and  indistinct,  so  that  the  choroidal  and 
sclerotic  rings  are  hidden  from  view,  and  the  optic  nerve  appears  to 
pass  gradually  over  into  the  retina,  without  any  sharply  defined  line  of 
demarcation.  The  retinal  vessels  are  also  somewhat  veiled,  and  covered 
by  a  pale  bluish-grey  film,  which  extends  to  some  distance  from  the 
disc  (perhaps  three  or  four  times  its  diameter),  and  hides  the  details  of 
the  subjacent  choroid.  The  retinal  hypersemia  may  extend  a  consider- 
able distance  beyond  this  serous  infiltration,  and  a  few  extravasations  of 
blood  are  often  noticed  scattered  about  on  difierent  portions  of  the 
retina.  As  the  disease  advances,  the  symptoms  of  venous  hyperaemia 
become  much  more  marked,  the  veins  look  turgid,  dark,  and  more 
tortuous,  the  smaller  veinlets  assuming  a  corkscrew  appearance.  The 
arteries,  on  the  other  hand,  are  narrowed  and  more  or  less  hidden  by 
the  infiltration.  The  optic  disc  becomes  more  swollen  and  infiltrated, 
and  its  outline  gradually  merged  into  the  retina.  The  infiltration  of 
the  disc  and  of  the  retina  is  of  a  serous  character,  and  gives  to  these 
parts  a  faint  greyish-rod  or  fawn-coloured  appearance,  interspersed  with 
delicate  greyish- white  striae,  which  arc  due  to  sclerosis  of  the  connective 

*  Vide  Forster's  very  interesting  paper  upon  this  subject  in  his  "  Ophthabno- 
logischo  Beitrage."     Berlin,  1862. 


RETINITIS   ALBUMINURICA.  337 

tissTxe  and  of  the  optic  nerve  fibres.  The  retinal  vessels  are  frequently 
interrupted  at  vai-ious  points  of  their  course,  by  being  covered  and  more 
or  less  hidden  by  the  exudation.  As  a  rule,  the  swelling  and  infiltra- 
tion of  the  optic  nerve  are  not  very  great  in  retinitis  albunainurica ; 
but  Ave  occasionally  meet  with  cases  in  which  the  reverse  obtains  and 
the  disc  assumes  the  peculiar  appearance  met  with  in  optic  neuritis.  It 
is  very  prominent,  swollen,  and  "woolly,"  and  of  a  greyish-red  and 
markedly  striated  appearance,  which  is  due  to  the  infiltration  occupying 
the  layer  of  the  optic  nerve  fibres.  The  outline  of  the  disc  is  indistinct 
and  irregular,  and  its  blood-vessels  more  or  less  completely  hidden  by 
the  infiltration.  According  to  Liebreich,  this  form  of  optic  neuritis 
may  occur  only  in  the  later  stages  of  nephritic  retinitis,  after  extensive 
degenerative  changes  in  the  retina  have  existed  for  some  length  of  time, 
or  it  may  precede  these,  or  even  exist  by  itself. 

Numerous  extravasations  of  blood  are  noticed  in  different  parts  of 
the  retina,  and  even  on  the  optic  disc.  They  vary  much  in  size  and 
shape,  and  lie  chiefly  in  the  internal  layers  of  the  retina,  as  is  shown  by 
their  striated  appearance,  and  the  fact  that  they  are  situated  on  the 
same  level  as  the  retinal  vessels,  some  of  which  may  even  be  partly 
covered  and  hidden  by  them.  The  haemorrhage  may,  however,  also 
occur  in  the  external  layers  of  the  retina,  or  between  the  latter  and  the 
choroid.  These  blood  extravasations  into  the  retina  are  often  very 
numerous,  and  of  considerable  size,  a  fact  at  which  we  cannot  be  sur- 
prised when  we  remember  that  the  coats  of  the  retinal  vessels  are  fre- 
quently extensively  diseased;  that  there  is  always  a  certain  degree  of  stasis 
in  the  retinal  circulation  produced  by  the  swelling  of  the  optic  nerve ; 
and  finally,  that  there  is  mostly  a  more  or  less  considerable  distiu'bance 
in  the  general  circulation,  owing  to  the  hypertrophy  of  the  left  ventricle, 
wdiich  is  so  frequently  met  with  in  Bright's  disease.  If  the  effusions 
of  blood  are  very  extensive,  they  may  alter  the  appearance  of  the 
exudation  very  considerably,  giving  to  it  a  dirty,  yellowish  red  tint. 

As  the  disease  of  the  retina  progresses,  w^e  notice  the  appearance  of 
small  wliite  spots  or  larger  patches  in  different  portions  of  the  retina,  at 
some  little  distance  from  the  optic  disc.  These  gradually  increase  in 
size,  and,  coalescing  with  each  other,  finally  form  a  broad  white  mound 
or  wall  round  the  optic  disc.  The  opacity  extends  especially  towards 
the  inner  side  of  the  retina,  and  somewhat  further  along  the  sides  of 
the  retinal  vessels.  This  white  mound  does  not  reach  close  up  to  the 
optic  disc,  but  is  always  separated  from  it  by  a  broad  zone  of  the  faint 
grey  or  fawn-coloured  infiltration,  in  the  centre  of  which  can  be 
indistinctly  traced  the  outline  of  the  disc.  The  peripheral  portion 
of  the  mound  is  irregular,  and  broken  up  here  and  there  into  small 
circumscribed  dots  of  exudation,  which  form  a  kind  of  fringe  round 
the  larger  figure.     In  the  region  of  the  yellow  spot  we  notice  a  very 

z 


338  DISEASES  OF   THE  RETINA. 

peculiar  appearance,  whicli,  as  was  first  pointed  out  by  Liebreich, 
is  especially  cliaracteristic  of  nephritic  retinitis,  viz.,  a  collection 
of  small,  stellated,  white,  glistening  figures,  which  look  just  as  if 
they  had  been  lightly  splashed  in  -with  a  small  brush.  Subsequently, 
if  the  exudation  increases  in  size,  these  stellated  spots  may  become 
merged  into  it,  and  this  peculiar  appearance  be  completely  lost.  The 
two  ophthalmoscopic  symptoms  which  are  most  characteristic  of  reti- 
nitis albuminuinca  are,  these  bright  stellated  dots  in  the  region  of  the 
yellow  spot,  and  the  broad  glistening  white  mound  which  encircles  the 
optic  disc.  But  it  must  be  stated  that  similar  appearances,  especially 
the  stellate  dots  may  be  met  with  in  other  forms  of  retinitis,  more 
particularly  in  neuro-retinitis ;  with  this  difference,  however,  that  the 
peculiar  grouping  of  the  ophthalmoscopic  appearances  is  not  the  same. 
In  a  case  of  neuro-retinitis  recorded  by  Von  Graefe,*  these  peculiar 
white  spots  in  the  macula  lutea  were  very  evident,  but,  as  he  points 
out,  such  cases  may  be  distinguished  from  neplii'itic  retinitis  by  the 
following  characteristics  : — (a),  that  the  white  spots  due  to  degenerative 
changes  in  the  retina  (neuro-retinitis)  are  situated  much  closer  to  the 
optic  disc ;  (b)  that  the  swelling  of  the  retina  in  the  vicinity  of  the 
disc  is  more  considerable ;  (c)  that  the  swelling  of  the  optic  nerve  is 
also  more  pronounced ;  and  (d)  that  the  veins  are  ranch  more  dilated 
and  tortuous,  which  lends  a  far  more  red  and  vascular  appearance  to 
the  optic  entrance. 

Retinitis  albuminurica  does  not,  however,  always  manifest  itself 
in  so  very  characteristic  a  form.  For  the  different  symptoms  above 
enumerated  may  assume  considerably  less  prominence,  or  some  of  them 
may  be  altogether  absent.  Thus  the  optic  disc  and  the  retina  in  its 
immediate  vicinity  may  appear  almost  normal,  and  there  may  only  be 
a  slight  alteration  in  the  retinal  vessels,  a  few  hgemorrhagic  eflPiisions, 
and  here  and  there  white  patches  of  exudation,  lying  either  isolated  or 
along  the  coats  of  the  vessels.  In  the  region  of  the  yellow  spot  these 
patches  assume  a  streaky  appearance  (Mauthner). 

Nephritic  retinitis  may  become  complicated  with  inflammatory 
changes  in  the  choroid  and  vitreous  humour,  or  with  detachment  of 
the  retina.  At  a  later  stage  atrophy  of  the  optic  nerve  and  of  the 
retina  may  close  the  scene. 

In  favourable  cases,  the  serous  infiltration,  the  effusion  of  blood 
and  certain  of  the  white  patches  may  subsequently  become  absorbed, 
so  that  the  retinal  vessels,  which  were  previously  hidden  at  certain 
points  of  their  course,  again  become  perfectly  apparent.  The  veins 
diminish  in  size  and  tortuosity,  and  the  arteries  become  more  filled 
with  blood.  We  may  now,  perhaps,  also  discover  changes  in  the 
epithelium    and    stroma  of  the  choroid,   which   had   been    previously 

*  "A.  f.  O.,"  vi,  2. 


RETINITIS  ALBUMINURICA.  339 

hidden  by  the  exudations  in  the  retina.  Sometimes,  we  moreover  find 
that  sclerosis  or  fatty  degeneration  of  the  coats  of  the  blood-vessels  has 
taken  place,  so  that  they  show  a  distinct  and  well-marked  white  margin. 
Whilst  there  can  be  no  doubt  that  the  serous  infiltration,  the  haBmorr- 
liagic  effusions,  the  fatty  degeneration  of  the  granular  layers,  and  the 
hypertrophy  of  the  connective  tissue  may  undergo  a  more  or  less  con- 
siderable degree  of  absorption,  tliis  does  not  appear  to  hold  good 
with  regard  to  the  sclerosis  of  the  optic  nerve  fibres,  which  remain 
unaltered. 

Let  us  now  briefly  glance  at  the  pathological  changes  which  occur  in 
the  retina  in  nephritic  retinitis,  and  give  rise  to  these  peculiar  and  cha- 
racteristic ophthalmoscopic  appearances.  The  serous  infiltration  of  the 
optic  nerve  and  retina  occui's  principally  in  the  connective  tissue 
elements,  and  especially  in  those  which  support  the  optic  nerve  fibres ; 
hence  the  striated  character  of  the  opacity,  which  is  partly  due  to  the 
serous  transudation,  and  partly  to  sclerosis  of  the  connective  tissue 
elements.  The  white  patches  and  the  large  white  glistening  wall 
which  encu'cles  the  optic  disc,  are  due  to  fatty  degeneration  of  the 
cellular  and  connective  tissue  elements  of  the  retina,  more  especially 
of  the  external  granular  layer.  The  striated  appearance  is  due  to 
hypertrophied  nerve  fibres,  or  sclerosis  of  the  connective  tissue.  The 
pecvxliar  little  stellated  white  dots  in  the  region  of  the  yellow  spot  are 
owing  to  fatty  degeneration  of  the  radial  connective  tissue  fibres.  The 
stellated  appearances  being  probably  due,  according  to  Schweigger,*  to 
the  peculiar  anatomical  arrangement  of  the  radial  fibres  at  the  yellow 
spot.  For  Bergmannf  has  shown  that  these  do  not  pass  perpendicu- 
larly through  the  retina,  but  are  slightly  curved  in  such  a  manner 
that,  as  they  pass  from  the  inner  to  the  outer  portion  of  the  retina, 
they  converge  towards  the  centre  of  the  yellow  spot.  The  optic  nerve 
fibres  also  undergo  sclerosis,  which  gives  rise  to  peculiar  opalescent 
spots.  These  are  often  arranged  in  little  clusters,  and  thus  pro- 
duce a  swelling  of  the  layer  of  the  optic  nerve  fibres.  Within  these 
little  clusters  of  sclerosed  nerve  fibres  may  also  be  noticed  globules 
of  fat.  It  is  of  great  importance,  as  far  as  the  prognosis  of  the  case 
with  regard  to  the  restitution  of  vision  is  concerned,  to  diagnose,  if 
possible,  this  condition  of  sclerosis  of  the  optic  nerve  fibres.  This  is, 
however,  difficult,  as  the  clusters  or  nests  of  sclerosed  nerve  fibres 
appear  with  the  ophthalmoscope  simply  as  little  white  spots  or  patches, 
very  like  those  which  are  due  to  fatty  degeneration.  Our  principal 
guide  must  be  their  position,  for  being  situated  in  the  innermost  layer 
of  the  retina,  they  will  lie  in  front  of,  and  upon  the  retinal  vessels,  and 
they  are  often  accompanied  by  small  extravasations  of  blood  (Schweig- 

*  "  A.  f.  O.,"  vi,  2,  312  ;  Lectures  on  the  Ophthalmoscope,  107. 
t  Henle  and  Pfeufei-'s  Zeitschriffc,  1854,  and  3  Reihe,  ii,  83. 

Z    2 


340  DISEASES   OF   THE   RETINA. 

ger).  Whereas  the  white  patches  due  to  fatty  degeneration,  are 
generally  situated  in  the  more  external  layers  of  the  retina,  and  there- 
fore lie  behind  the  vessels. 

The  extent  to  which  the  connective  tissue  and  the  nerve  elements 
of  the  retina  are  affected,  does  not  necessarily  correspond.  Sometunes, 
the  latter  may  be  extensively  implicated,  the  connective  tissue  being 
at  the  same  time  but  nioderately  or  only  slightly  affected.  In  such  a 
case,  the  sight  will  be  much  more  seriously  and  permanently  impaii'ed 
than  if  the  reverse  obtains. 

Heinrich  Miiller*  has  also  noticed  sclerosis  of  the  chorio-capillaris, 
on  account  of  which,  the  calibre  of  the  vessels  is  greatly  narrowed  or 
they  are  even  obliterated  at  certain  points.  The  peculiar  fibrillar 
appearances  occurring  at  the  periphery  of  the  vitreous  humour  which 
he  described,  are  supposed  by  Schweigger  to  be  probably  due  to  post- 
mortem changes. 

The  coats  of  the  retinal  vessels  are  also  frequently  affected  with 
sclerosis  or  fatty  degeneration,  and  in  the  larger  branches  the  tunica 
adventitia  is  often  considerably  hypertrophied,  so  that  the  cahbre  of  the 
vessel  is  diminished  in  size,  and  it  appears  like  a  white  band  with  a 
central  red  line. 

The  sight  is  generally  considerably  impaired,  and  the  patients  have 
sometimes  become  hypermetropic,  which  is  evidently  due  to  the 
thickening  of  the  retina,  in  consequence  of  which  it  now  lies  within 
the  focal  distance  of  the  eye.  This  hypermetropic  state  of  the  refrac- 
tion is  very  evident  with  the  ophthalmoscope,  the  retinal  vessels  and 
details  of  the  fundus  being  quite  visible  in  the  erect  image  at  some  httle 
distance  from  the  patient,  and  moving  in  the  same  direction  as  the  head 
of  the  observer.  Sometimes,  the  patient  is  still  able  to  read  medium-sized 
type,  in  other  cases,  he  can  only  decipher  the  largest  print,  or  count 
fingers  with  difficulty.  The  field  of  vision,  on  the  contrary,  is  often  not 
at  all  contracted,  and  only  perhaps  somewhat  impaired  at  the  very  peri- 
phery, whilst  the  central  vision  may  be  greatly  deteriorated.  We  often 
find,  however,  that  there  are  gaps  in  the  field,  certain  portions  being  more 
or  less  impaired,  and  that  these  correspond  to  the  portions  of  the  retina 
in  which  the  inflammatory  changes  are  most  marked  and  extensive.  I 
must  here  call  special  attention  to  the  fact,  that  the  impairment  of 
vision  does  not  necessarily  correspond  with  the  striking  changes  in  the 
retina  presented  by  the  ophthalmoscopic  appearances.  For  the  most 
marked  and  conspicuous  symptoms,  the  white  patches  and  the  glisten- 
ing white  mound,  ai'e  chiefly  due  to  fatty  and  hypertropliic  changes  in 
the  connective  tissue  and  cell  elements  of  the  retina,  and  are  capable 
of  absolution.     And  hence  these  pathological  changes  are  not  of  such 

*  "VVurzburger,  "  Medicinische  Zeitsclirift ,"  i,  1,1860;  vide  also  translation  of 
this  paper  by  the  author,  "K.  L.  O.  H.  Reports,"  iii,  51. 


RETINITIS   ALBUMINURIC  A.  341 

importance  with  regard  to  tlie  state  of  vision  as  those  which  implicate 
the  nerve  elements.  But  these  alterations  in  the  nerve  elements 
afford  far  less  striking  ophthalmoscopic  appearances  than  those  due  to 
fatty  degeneration.  The  impaii'ment  of  sight  in  nephritic  retinitis  is 
generally  slowly  progressive,  and  this  will  guard  us  against  confounding 
it  with  the  sudden  attacks  of  amaurosis  which  are  met  with  in  cases  of 
Bright's  disease,  and  which  do  not  depend  upon  inflammation  of  the 
retina,  but  upon  urtemia.  In  the  latter  case,  the  attacks  occur  with 
startlmg  suddenness,  so  that  the  patient  may  become  perfectly  blind 
within  a  few  minutes  or  houj's,  the  recovery  being  as  rapid.  Moreover, 
there  are  always  present  marked  general  symptoms  of  ursemic  poisoning, 
such  as  intense  headache,  vertigo,  loss  of  consciousness,  sickness, 
epileptoid  convulsions,  etc.  The  ophthalmoscopic  symptoms  in  these 
cases  of  nrsemic  amblyopia  are,  moreover,  quite  negative.  But  we  may 
not  unfrequently  have  a  mixture  and  succession  of  symptoms  of  ambly- 
opia dependent  upon  the  retinitis  and  upon  ureemia.  Thus  nephritic 
retinitis  has  perhaps  existed,  to  a  more  or  less  advanced  degree,  for 
some  time,  giving  rise  to  a  certain  amount  of  amblyopia,  and  suddenly 
the  latter  is  greatly  increased  by  an  attack  of  uraemia.  Mooren*  has 
noticed  the  very  rapid  development  of  a  high  degree  of  hypermetropia 
in  cases  of  uremic  amblyopia. 

It  was  at  one  time  supposed  by  some  observers  (especially  Ladouzy) 
that  the  amblyopia  is  sometimes  premonitory  of  and  precedes  the 
disease  of  the  kidney.  But  this  is  not  so,  the  affection  of  the  retina 
occurs  only  when  the  nephritis  (either  acute  or  chronic)  is  already 
fully  developed,  and  also  in  its  later  stages,  more  especially  together 
with  the  small,  contracted  kidney.  It  is,  however,  also  observed  in 
the  large  flabby  kidney. 

Sometimes  indeed,  the  amblyopia  is  the  only  marked  synaptom, 
the  affection  of  the  kidney  being  unknown  and  unsuspected  by  the 
patient  and  his  medical  adviser.  In  some  of  these  cases  there  are, 
however,  sj-mptoms  of  derangement  of  the  digestive  functions,  nausea, 
sickness,  etc.  We  are  consulted  as  to  the  condition  of  the  sight,  the 
ophthalmoscope  reveals  the  symptoms  of  retinitis  albuminurica,  the 
urine  is  tested  for  albumen,  and  then  it  is  discovered  that  the  patient  is 
suffering  from  Bright's  disease.  The  affection  of  the  retina  attacks 
both  eyes,  either  simultaneously  or  at  a  short  interval. 

Hypertrophy  and  dilatation  of  the  left  ventricle  are  almost  con- 
stantly met  with;  indeed,  in  32  cases  Von  Graefe  found  them  present 
in  all.  The  frequent  occurrence  of  extensive  retinal  haemorrhages  is 
probably  also  due  to  the  disturbance  in  the  circulation  caused  by  the 
hypertrophy,  although  it  must  also  be  remembered  that  the  coats  of 
the  blood-vessels  are  often  diseased.  That  nephritic  retinitis  may, 
*  Mooren,  "  Ophthalmiatrische  Beobachtungen,"  1867,  p.  287. 


M2  DISEASES   OF   THE   RETINA. 

however,  occur  without  hypertrophy  and  dilatation  of  the  left  ventricle 
is  proved  by  cases  recorded  by  Mandelstamm  and  by  Homer.  The 
former*  found  that  out  of  13  cases  of  retinitis  albuminurica,  hyper- 
trophy of  the  left  ventricle  was  only  present  in  two. 

Great  uncertainty  still  exists  as  to  the  connecting  link  between  the 
affection  of  the  kidney  and  that  of  the  retina.  The  cause  is  yet 
unknown  why,  together  with  Bi-ight's  disease,  we  should  so  frequently 
meet  with  a  special  form  of  retinitis,  the  ophthalmoscopic  symptoms  of 
which  are  so  constant  and  pecuhar,  both  in  the  grouping  and  localiza- 
tion, that  from  their  appearance  alone  we  are  able  to  diagnose  with 
certainty  the  presence  of  albuminuria. 

It  has  been  supposed  by  some,  that  the  inflammation  and  degenera- 
tion of  the  retina  are  due  to  an  impairment  of  the  nutrition  of  the 
latter,  dependent  upon  the  great  amount  of  urea  in  the  blood.  By  other 
observers  (especially  Traubej)  it  has  been  thought,  that  the  secondary 
increase  in  the  tension  of  the  aortic  system  forms  the  starting  point  of 
the  disease.  In  favour  of  the  latter  opinion,  we  must  admit  the 
extreme  frequency  of  hypertrophy  and  dilatation  of  the  left  ventricle  as 
an  accompaniment  of  neplmtic  retinitis,  as  also  the  constant  occurrence 
of  more  or  less  extensive  extravasations  of  blood  in  the  retina  at  the 
outset  of  the  disease. 

The  prognosis  as  to  the  degree  of  sight  that  may  be  regained  by  the 
patient,  must  depend  upon  the  extent  to  which  the  pathological  changes 
in  the  retina  have  advanced,  and  still  more  upon  the  degree  to  which 
the  nervous  elements  of  the  retina  have  suffered.  It  has  been  already 
stated  that  many  of  the  inflammatory  products  may  become  absorbed. 
If  this  occurs,  and  the  nerve  elements  have  been  but  slightly  implicated, 
vision  may  be  restored  almost,  or  even  quite,  to  the  normal  condition. 
It  is  diflerent,  if  the  nerve  tissue  has  been  extensively  afiected,  for  then 
we  find  that  even  although  the  large  white  patches,  the  serous  infiltra- 
tion, and  the  blood  extravasations  become  to  a  great  extent  absorbed, 
serious  impairment  of  sight  remains  behind.  Sometimes  atrophy  of 
the  optic  nerve  may  even  ensue,  especially  if  it  has  been  much  impli- 
cated in  the  inflammation.  As  a  rule,  however,  nephritic  retinitis  leads 
only  very  exceptionally  to  complete  blindness. 

There  is  no  direct  connection  between  the  improvement  in  the  sight 
and  the  absorption  of  the  exudations,  etc.,  and  the  amount  of  albumen 
in  the  urine,  or  the  condition  of  the  kidney  disease,  for  the  former 
may  occur  without  any  amelioration  in  the  constitutional  afiection. 
The  best  prognosis  is  afforded  by  those  cases  in  which  the  albuminuria 
occurs  in  advanced  pregnancy,  after  scarlatina,  typhoid  fever,  etc. 

The  treatment  must  be  chiefly  directed  towards  the  primary  disease. 

*  Pagonstecher,  "Klinisclie  Beobachtuugen,"  1866,  p.  80. 
t  "  Deutsche  Klinik.,"  1859,  p.  314. 


RETINITIS   SYPHILITICA.  343 

I  have  found  most  benefit  from  the  use  of  tonics,  more  especially  the  tinc- 
ture of  the  muriate  of  iron,  or  from  the  citrate  of  quinine  and  steel.  The 
free  action  of  the  skin  should  bo  encouraged  and  maintained.  If  symp- 
toms of  ursemic  poisoning  supervene,  diaphoretics  and  purgatives  should 
be  freely  administei-ed.  The  only  local  application  from  which  I  have 
found  any  benefit  is  the  artificial  leech.  In  those  cases  in  which  it  is 
unadvisable  to  abstract  blood  on  account  of  the  anajmic  condition  of  the 
patient,  I  apply  the  dry  cup  to  the  temple,  and  have  often  seen  this 
followed  by  marked  improvement  in  the  vision.  It  is  to  be  repeated  at 
intervals  of  five  or  six  days. 

The  patient  should,  of  course,  be  warned  not  to  expose  hinaself  to 
the  effects  of  very  glaring  light,  nor  should  he  be  permitted  to  use  his 
eyes  for  reading  or  working. 

4— RETINITIS  LEUC^MICA. 

Liebreich  has  several  times  noticed  a  peculiar  affection  of  the  retina 
in  connection  with  leucocythemia.  It  is  chiefly  characterised  by  the 
great  palor  of  the  retinal  vessels,  more  especially  the  veins,  which  are 
of  a  faint  rose  colour,  even  although  they  may  be  dilated  and  tortuous. 
The  optic  disc  is  likewise  very  pale,  there  is  a  striated  opacity  in  its 
vicinity,  and  small  irregular  patches  in  the  region  of  the  yellow  spot. 
Finally,  at  the  periphery  of  the  fundus  are  noticed  a  number  of 
brilliant  white  circular  spots,  which  greatly  resemble  those  met  with  in 
Bright's  disease.  In  one  case  of  retinitis  leucasmica,  which  was  examined 
by  Liebreich  with  the  ophthalmoscope,  Recklingshausen  subsequently 
found,  on  microscopical  examination,  that  these  white  spots  were  due  to 
the  same  form  of  sclerosis  of  the  optic  nerve  fibres  as  that  described  by 
H.  Miiller  in  Bright's  disease. 

An  admirable  illustration  of  retinitis  leucaemica  is  given  in  Liebreich's 
Atlas  der  Ophthalmoscopic,  Plate  x,  fig.  3. 

6.— RETINITIS  SYPHILITICA. 

A  peculiar  form  of  retinitis  is  sometimes  met  with  in  persons  suffer- 
ing from  constitutional  syphilis,  and  as  it  affords  certain  characteristic 
symptoms  it  is  occasionally  possible  to  diagnose  the  nature  of  the 
malady  from  the  ophthalmoscopic  appearances  alone.  It  must  be 
admitted,  however,  that  the  latter  may  in  some  cases  be  so  slightly 
marked,  that  our  diagnosis  as  to  the  syphilitic  nature  of  the  disease 
must  chiefly  depend  upon  the  general  history  of  the  case,  and  upon  the 
presence  of  other  symptoms  of  constitutional  syphilis. 

At  the  outset,  there  is  simply  hypersemia  of  the  optic  disc  and  retina. 


344  DISEASES  OP   THE   RETINA. 

The  retinal  veins  are  somewhat  dilated,  dark,  and  tortuous,  but  not 
markedly  so,  and  the  venous  congestion  diminishes  as  the  disease  pro- 
gresses. Sometimes,  the  venous  hyperemia  is  only  partial.  The 
retinal  arteries  are  attenuated  and  diminished  in  size.  The  optic  disc 
is  slightly  swollen,  and  its  outline  hazy  and  ill-defined.  The  disc  as 
well  as  the  surrounding  retina  are  veiled  by  a  faint  bluish-grey  film, 
which  is  due  to  a  serous  transudation  of  the  optic  nerve  and  retina. 
This  film  is  often  extremely  delicate  and  faint,  assuming  perhaps  only 
the  appearance  of  an  exaggeration  of  the  physiological,  grey  reflex  which 
the  retina  of  normal,  darkly  pigmented  eyes  presents.  This  uniform 
bluish-grey  opacity  does  not  extend  regularly  in  all  directions  from  the 
optic  nerve,  but  is  often  principally  developed  in  certain  parts  of  the 
retina,  and  more  especially  along  the  course  of  the  vessels,  whence  it 
shades  off  gradually  and  imperceptibly  into  the  healthy  retina.  In  the 
vicinity  of  the  disc,  the  opacity  is  markedly  striated.  Although  minute 
punctiform  opacities  generally  occur  in  the  region  of  the  yellow  spot, 
they  are  not  so  brightly  glistening,  or  arranged  in  the  peculiar  stellate 
manner  as  those  met  with  in  nephritic  retinitis,  but  are  strewn  about 
irregularly.  They  are,  moreover,  distinguished  from  these,  by  the  fact 
that  they  undergo  very  rapid  changes,  perhaps  disappearing  and  re-ap- 
pearing in  the  course  of  a  few  days,  the  sight  at  the  same  time  under- 
going corresponding  fluctuations.  The  spots  in  Bright's  disease  are 
on  the  other  hand  very  persistent,  and  their  remains  may  often  be 
distinctly  traced  even  many  months  after  the  acute  retinitis  has  passed 
away,  and  its  residue  alone  remains,  or  atrophy  of  the  disc  has  set  in. 
We  also  sometimes  meet  with  a  peculiar  tawny,  reddish-brown  tint  in 
the  region  of  the  yellow  spot  in  syphilitic  retinitis. 

The  inflammatory  changes  in  syphilitic  retinitis  consist  cliiefly  in  a 
serous  infiltration  of  the  retina,  and  sclerosis  of  the  connective  tissue 
elements,  more  especially  of  the  vertical  trabecular  fibres  (stiitz  fasern), 
hence  also  the  striated  character  of  the  opacity.  The  other  portions  of 
the  retina  are  generally  exempt  from  inflammatory  and  degenerative 
changes,  but  this  is  not  always  the  case,  and  thus  may  arise  a  mixed 
form  of  syphilitic  retinitis,  in  which  the  special  and  pathognomonic 
symptoms  are  accompanied,  and  perhaps  somewhat  masked,  by  other 
changes  in  the  parenchyma,  and  great  swelling  of  the  optic  nerve. 
Thus  white  spots  or  patches  may  be  noticed  in  the  retina.  These  may 
occur  in  small  isolated  patches,  or  in  the  form  of  large  striped  opacities 
situated  in  the  innermost  layer  of  the  retina ;  their  pressure  perhaps 
causing  complete  emptiness  of  some  of  the  vessels,  Avhich  are  changed 
into  white  bloodless  bands  (Liebreich).  These,  however,  are  never  so 
brilliantly  white  as  the  spots  met  with  in  nephritic  retinitis. 

As  a  rule,  retinal  haemorrhages  are  not  usually  met  with  in  syphilitic 
retinitis,  or  only  to    a  very  moderate  extent.     Sometimes,   however, 


RETINITIS   SYPHILITICA.  345 

cases  occur  in  wliicli  numerous  and  extensive  extravasations  of  blood 
are  noticed,  which  may  be  situated  in  different  layers  of  the  retina,  and 
also  between  it  and  the  choroid.  Syphilitic  retinitis  is  not  unfrequently 
associated  with  inflammation  of  the  choroid,  and  occasionally  with  irido- 
choroiditis,  or  iritis.  If  the  symptoms  of  the  inflammation  of  these 
tunics  are  very  pronounced,  the  affection  of  the  retina  may  be  overlooked, 
more  especially  if  the  vitreous  humour,  as  is  often  the  case,  is  diffusely 
clouded  and  traversed  by  dark  flakes,  and  the  details  of  the  fundus  are 
thus  rendered  indistinct.  Care  must  be  taken  not  to  mistake  such  an 
indistinctness  of  the  optic  disc  and  retina  for  that  dependent  upon 
retinitisj  or  to  diagnose  the  presence  of  the  latter  simply  from  the  great 
impairment  of  vision.  A  practised  and  careful  ophthalmoscopist  would 
not,  however,  fall  into  such  errors  of  diagnosis. 

Together  with  the  symptoms  of  syphilitic  retinitis,  we  often  notice 
certain  more  or  less  extensive  changes  in  the  choroid.  These  may  occur 
either  in  the  vicinity  of  the  retinal  opacity,  at  some  distance  from  it, 
or  be  chiefly  confined  to  the  periphery  of  the  fundus.  These  changes 
consist  principally  in  a  thinning  and  discoloration  of  the  epithelial  layer, 
the  pigment  cells  of  which  are  collected  together  into  small  masses, 
giving  rise  to  more  or  less  considerable  groups  of  small  grey  dots 
intermixed  with  little  black  spots,  which  are  aggregations  of  pigment 
cells.  The  latter  may,  perhaps,  subsequently  invade  the  retina 
(Liebreich).  In  other  cases  the  inflammatory  changes  affect  the  deeper 
portions  of  the  choroid,  and  we  then  notice  large  grey  patches  in 
which  the  pigment  cells  of  the  epithelial  layer  and  stroma  of  the 
choroid  ai'e  absent,  so  that  the  choroidal  vessels  can  be  distinctly 
seen ;  such  patches  being  generally  fringed  by  a  dark  black  zone  of 
pigment. 

Syphilitic  retinitis  generally  occurs  together  with,  or  shortly  after 
the  appearance  of  secondary  symptoms,  and  is  sometimes,  as  has  already 
been  stated,  accompanied  by  inflammation  of  other  tunics  of  the 
eye,  such  as  choroiditis  or  irido-choroiditis.  It  may  also  be  due  to 
hereditary  syphilis  (Hutchinson). 

The  course  of  the  disease  is  generally  slow,  lasting  many  weeks  or 
even  months,  and  relapses  are  very  apt  to  occur. 

The  sight  often  diminishes  rapidly,  so  that  in  the  course  of  a  few 
days  the  patient  may  be  only  able  to  decipher  N'o.  16  or  20  of  Jiiger, 
and  may  become  greatly  impaired,  more  especially  if  the  region  of  the 
yellow  spot  is  much  affected.  We  find  also,  that  the  condition  of  the 
sight  fluctuates  considerably  with  the  presence  or  absence  of  the  little 
punctiform  opacities  in  the  macula  lutea.  Another  interesting  phe- 
nomenon is  the  frequency  of  micropsia  in  syphilitic  retinitis.  The  field 
of  vision  is  often  either  not  at  all,  or  only  slightly  impaired,  but  it  fre- 
quently shows  peculiar  circumscribed  zonular  defects  in  the  vicinity  of 


346  DISEASES   OF  THE  RETINA. 

the  yellow  spot,  to  which,  as  well  as  the  frequent  presence  of  photopsies, 
particular  attention  has  been  called  by  Mooren. 

The  prognosis  of  the  disease  is  favourable,  more  especially  if  the 
patient  is  seen  at  a  very  early  period  of  the  attack.  Although  the 
sight  may  be  considerably  impaired,  the  inflammatory  changes  in  the 
retina  do  not,  as  a  rule,  affect  the  nervous  elements,  but  chiefly  consist 
in  a  serous  infiltration  of  the  retina,  and  hypertrophy  and  sclerosis  of 
the  connective  tissue.  But  if  the  latter  is  greatly  hypertrophied,  it 
will  press  upon  the  nerve  elements,  and  may  thus  even  lead  to  their 
atrophy.  There  is  much  tendency  to  relapses,  either  after  the  attack 
has  completely,  or  nearly  completely  subsided,  or  as  the  disease  is  pro- 
gressing towards  recovery.  By  the  reciirrence  of  such  relapses,  the 
ultimate  functional  condition  of  the  retina  may,  of  course,  be  greatly 
endangered. 

In  treating  syphilitic  retinitis  we  must  place  our  chief  reliance 
upon  mercury,  for  the  greatest  benefit  is  generally  experienced  from 
bringing  the  patient  rapidly  under  its  influence.  This  may  be  done 
either  by  its  administration  internally,  or  by  the  inunction  of  the 
mercurial  ointment.  I  myself  prefer  the  latter  method,  and  generally 
prescribe  from  5ss.  to  5j-  of  the  ointment  to  be  rubbed  into  the  inside 
of  the  arms  and  thighs  three  times  daily,  and  this  mostly  causes  saliva- 
tion in  the  coui'se  of  a  few  days.  If  the  patient  has  been  recently 
salivated,  a  combination  of  iodide  of  potassium  and  bichloride  of 
mercury  should  be  given. 

As  the  hj^ersemia  and  congestion  of  the  retina  are  generally  not 
marked,  the  application  of  the  artificial  leech  is  not  always  indicated. 

Under  the  name  of  "  central  recurrent  retinitis,"  Yon  Graefe*  has 
described  a  very  rare  and  interesting  form  of  syphilitic  retinitis,  which 
is  especially  characterised  by  its  being  confined  to  the  region  of  the 
yellow  spot,  and  by  its  marked  tendency  to  recur  very  frequently.  He 
has  known  it  recur  10,  20,  30,  and  in  one  case  more  than  80  times. 
The  attack  is  generally  very  sudden,  and  disappears  again  in  the  course 
of  a  few  days,  but  a  relapse  occurs  in  from  a  fortnight  to  three  months. 
At  first,  there  is  generally  no  impairment  of  sight  during  the  intervals 
between  the  attacks,  but  afterwards,  when  the  latter  become  more  pro- 
longed, some  amblyopia  remains.  When  the  attack  is  about  to  occur, 
the  patient  notices  a  dark,  irregular  spot  in  the  centre  of  the  field  of 
vision,  or  certain  portions  of  the  latter  are  obscured.  The  sight  is 
always  greatly  impaired,  so  that  the  largest  letters  can  hardly  be 
deciphered.  If  both  eyes  are  affected  simultaneously,  the  patient  is 
almost  perfectly  bhnd,  and  quite  unable  to  guide  himself.  During 
the  attack  there  is  generally  some  photophobia,  and  perhaps  some  slight 
ciliary  injection,  more  especially  in  the  morning  on  awaking.  Ophthal- 
*  "  Archiv.  f.  Oplithalmologie,"  xii,  2,  211. 


RETINITIS   APOPLECTICA.  347 

moscopically,  the  affection  may  be  distiug-uished  from  the  eom.mou 
syphilitic  retiriitis,  by  the  fact  that  the  delicate  bluish-green  film  of 
opacity  is  confined  to  the  region  of  the  yellow  spot,  culminating  around 
the  fovea  centralis,  and  gradually  and  uniformly  shading  ofi'  towards 
the  periphery  of  this  region.  The  vicinity  of  the  optic  disc  is  quite 
free  from  opacity.  Sometimes,  small,  dehcate,  white  dots  are  noticed 
in  the  opacity,  which  are,  perhaps,  arranged  in  Kttle  groups,  but  they 
do  not  present  the  brilliantly  white,  lustrous  appearance  of  fat  granules. 
The  eflfusion  in  the  yellow  spot  becoraes  developed  during  the  attack, 
but  is  preceded  by  the  functional  disturbances,  and  these  again  disappear 
sooner  than  the  efiusion.  In  the  more  recent  cases  the  latter  disappears 
completely  during  the  intervals  of  the  attacks,  but  at  a  later  stage  a 
faint,  grey  opacity  remains  behind  in  the  close  proximity  of  the  fo^^ea 
centralis.  In  one  case,  in  which  a  great  number  of  relapses  were  closely 
watched  during  six  years,  the  opacity  contained  irregular  masses  of 
dark  blue  pigment. 

This  affection  is  undoubtedly  due  to  syphiHs,  but  does  not  show 
itself  until  a  very  long  period  (sometimes  many  years)  after  the  second- 
ary constitutional  symptoms. 

Von  Graefe  has  only  found  the  long-continued  or  repeated  use  of 
inunction  of  mercury  beneficial.  The  intervals  between  the  attacks 
become  longer,  and  the  latter  less  severe,  until  they  gradually  become 
extinguished.  Whether  or  not  the  sight  will  be  completely  restored, 
will  depend  upon  the  fact  whether  permanent  changes  have  taken  place 
in  the  retina.     Marked  micropsia  was  noticed  in  several  cases. 


6.— RETINITIS  APOPLECTICA  (Plate  VI.,  Fig.  7). 

In  this  affection  we  find,  that  together  with  more  or  less  hypercemia 
and  oedema  of  the  optic  nerve  and  retina,  there  is  an  extreme  tendency 
to  extravasation  of  blood  into  the  retina.  The  condition  of  the  optic 
nerve  varies  considerably,  in  some  cases,  there  is  only  a  moderate  degree 
of  hypersemia  and  serous  infiltration,  rendering  the  disc  somewhat 
indistinct,  and  its  outline  irregular ;  in  others,  the  disc  is  of  a  deep  red 
tint,  and  its  margin  so  ill-defined,  that  it  can  only  be  distinguished  from 
the  surrounding  retina  by  the  emergence  of  the  retinal  vessels.  The 
veins  are  dark,  much  dilated,  and  very  tortuous,  and  along  their 
course,  more  especially  at  their  points  of  division,  are  seen  numerous 
extravasations  of  blood.  The  arteries  may  retain  their  normal  appear- 
ance, but  generally  become  attenuated,  and  sometimes  changed  into 
white,  bloodless  bands.  The  extravasations  of  blood  vary  much  in 
number,  extent,  and  situation.  They  occur  very  frequently  in  the 
inner  laj'er  of  the  retina,  and  are  then  characterised  by  their  peculiai'ly 


348  DISEASES   OF   THE  RETINA. 

irregular  and  striated  appearance,  and  also  by  tlie  fact  that  they  cover  the 
blood-vessels  more  or  less  completely,  or  that  the  continuity  of  the  latter 
is  interrupted,  the  gap  being  occupied  by  the  heemorrhage.  The  blood 
frequently  makes  its  way  from  the  optic  nerve  layer  through  the 
retina,  the  elements  of  which  it  pushes  aside,  to  the  outer  layers,  or 
even  to  the  choroid,  so  that  the  haBmorrhages  may  be  situated  in  the 
more  external  portions  of  the  retina,  or  between  this  and  the  choroid. 
In  such  cases  the  effusions  will  be  more  sharply  defined,  uniform, 
and  cii'cular,  and  be  distinctly  situated  beneath  the  retinal  vessels. 
Effusions  of  blood  into  the  retina  always  show  more  tendency  to  extend 
outwards  towards  the  choroid,  than  inwards  towards  the  vitreous 
humour,  where  the  internal  membrana  limitans  offers  a  stronger  bar- 
rier to  them.  They  may,  however,  break  into  the  vitreous,  and  pro- 
duce dense  opacities.  Sometimes,  however,  they  extend  along  the 
inner  sui^face  of  the  retina,  and  then  give  rise  to  large,  uniform,  smooth- 
looking  red  patches,  which  completely  cover  and  hide  the  vessels. 
The  hsemorrhagic  effusions  occur  in  different  portions  of  the  retina, 
and  may  be  chiefly  confined  to  the  vicinity  of  the  optic  disc  or  yellow 
spot,  or  to  the  periphery  of  the  fundus.  Extravasations  may  also  occur 
on  the  disc. 

There  are  generally  no  exudative  or  degenerative  changes  of  the 
retina,  such  as  are  met  with  in  other  forms  of  retinitis,  there  being 
only  a  serous  infiltration,  often  very  slight,  in  and  around  the  optic 
nerve. 

The  effusions  of  blood  retain  their  colour  for  a  very  long  time,  more 
especially  in  old  people,  and  then  breaking  up,  they  either  slowly 
undergo  absorption,  or  become  changed  into  a  dark  crumbling  mass 
(Liebreich).  In  the  former  case  they  gradually  assume  a  lighter, 
greyish  tint,  which,  commencing  at  the  edge  of  the  extravasation,  slowly 
extends  to  the  whole,  the  blood  being  gradually  absorbed.  Sometimes 
these  extravasations  undergo  fatty  or  pigmentary  degeneration.  The 
latter  occurs  sooner  in  blood  effused  into  the  vitreous,  than  when  it  is 
situated  in  the  retina  (Liebreich).  The  disease  shows  a  great  tendency 
to  relapses,  and  in  this  is  to  be  found  one  of  its  chief  dangers,  for  if  they 
occur  frequently,  or  to  a  considerable  extent,  the  function  of  the  retina 
may  be  greatly  impaired,  and  even  atrophy  of  the  optic  nerve  and 
retina  ensue.  The  prognosis  should  therefore  always  be  guarded, 
especially  if  the  extravasations  are  numerous,  and  situated  in  the 
yellow  spot.  The  sight  is  in  some  cases  not  very  markedly  affected, 
or  not  in  a  degree  corresponding  to  the  striking  ophthalmoscopic 
appearances  presented  by  the  numerous  and  extensive  haemorrhages. 
This  depends  entirely  upon  which  part  of  the  retina  is  the  seat  of  the 
effusions.  If  the  latter  have  occurred  at  tlie  periphery,  the  sight  may 
be  quite  unaffected ;  if  in  the  yellow  spot,  it  will  be  greatly  impaired. 


RETINITIS  PIGMENTOSA.  349 

Sometimes  the  attack  is  extremely  sudden,  a  patient  finding  that  in 
the  course  of  a  few  moments,  or  on  awaking  in  the  morning  he  has 
become  nearly  absolutely  blind.  The  patients  at  the  same  time  often 
experience  a  feeling  of  dizziness  and  faintness.  The  field  of  vision  is 
not  unfrequently  somewhat  contracted,  and  shows  more  or  less  exten- 
sive interruptions  or  gaps,  or  there  may  appear  in  it  grey  shadows  or 
black  spots,  which  are  in  all  probability  due,  as  was  pointed  out  by 
Heymann,  to  entoptic  shadows  thrown  by  the  blood  extravasations 
upon  the  sensitive  elements  of  the  retina. 

Retinitis  apoplectica  occurs  frequently  together  with  disturbances 
of  the  general  circulation,  which  may  be  due  to  affections  of  the 
uterus,  Uver,  or  the  heart ;  thus  it  is  not  unfrequently  seen  together 
with  suppression  of  the  menses,  hypertroj)hy  and  dilatation  of  the 
left  ventricle,  and  aflFections  of  the  aortic  valves.  Also,  if  any  impedi- 
ment exists  to  the  venous  reflux  from  the  eye,  either  ft'om  tumours 
etc.,  pressing  upon  the  optic  nerve  within  the  orbit,  or  situated  within 
the  cranium.  In  such  cases,  however,  the  blood  extravasations  are  gene- 
rally soon  followed  by  oedema  and  inflammation  of  the  optic  nerve. 
Another  frequent  cause  is  fatty  or  atheromatous  degeneration  of  the 
coats  of  the  blood-vessels,  and  it  is  consequently  often  met  with  in  old 
persons,  and  in  such  cases  it  may  be  of  prognostic  importance,  as  it 
leads  us  to  suspect  that  the  vessels  of  the  brain  may  also  be  degene- 
rated, and  that  imminent  danger  may  consequently  be  apprehended. 
The  treatment  must  consist  chiefly  in  attempting  to  remove  the  cause, 
and  preventing  if  possible  a  recurrence  of  the  disease.  Diui-etics  and 
saline  aperients,  more  especially  mineral  waters  are  often  of  much 
benefit.     Locally  the  artificial  leech  should  be  employed. 

7.— RETINITIS  PIGMENTOSA  (Plate  III.,  Fig.  5). 

This  disease  is  principally  characterised,  as  its  name  suggests,  by 
the  presence  of  pigment  in  the  retina,  which  gives  rise  to  a  most 
peculiar  and  unmistakeable  appearance,  more  especially  when  the  pig- 
ment is  deposited  in  considerable  quantity.  In  the  latter  case,  we 
notice  that  the  greater  portion  of  the  retina  is  covered  by  lai-ge  black 
masses,  which  are  arranged  chiefly  along  the  course  of,  and  in  close 
proximity  to  the  retinal  vessels. 

On  close  examination,  we  find  that  these  black  masses  of  pigment 
consist  of  circular  or  ii-regular  shaped  spots  ;  of  larger  black  spots  with 
long  naiTow  prolongations,  and  which  are  hence  often  likened  to  bone 
corpuscles  ;  and  of  narrow  black  hnes  running  along  the  side  of  a  vessel 
or  completely  covering  it.  On  account  of  the  deposits  of  pigment  along 
the  coats  of  the  vessels,  the  latter  often  appear,  for  a  certain  portion  of 


o50  DISEASES  OF   THE   RETINA. 

their  course,  changed  into  fine  black  lines.  At  the  division  of  the  vessels 
the  pigment  deposits  assume  a  peculiarly  characteristic  stellate  appear- 
ance. The  pigment  is  sometimes  deposited  along  the  course  of  vessels 
which  are  still  pervious  and  carry  blood.  For  an  illustration  of  the 
ophthalmoscopic  appearances  of  retinitis  pigmentosa,  vide  Plate  III, 
fig.  5. 

These  deposits  of  pigment  always  exist  in  the  greatest  number  at 
the  periphery  of  the  fundus,  where  they  first  make  their  appearance, 
and  whence  they  gradually  extend  towards  the  posterior  pole  of  the  eye, 
so  that  they  form  a  more  or  less  broad  girdle,  which  encircles  the  cen- 
tral portion  of  the  retina ;  but  at  a  later  period  the  region  of  the  yellow 
spot  also  becomes  invaded  by  the  disease.  The  pigment  appears  to  be 
as  a  rule  first  developed  at  the  inner  (nasal)  side  of  the  retina ; 
indeed  it  always  remains  more  extensive  on  this  than  on  the  temporal 
side.  The  retinal  vessels  undergo  in  this  disease  certain  constant  and 
marked  changes,  which  evidently  greatly  influence  the  condition  of 
hemeralopia  and  contraction  of  the  field  of  vision.  These  changes  con- 
sist in  a  thickening  of  the  coats  of  the  retinal  vessels,  and  a  consequent 
diminution  in  their  calibre ;  they,  however,  retain  their  transparency, 
and  simply  appear  diminished  in  size,  and  this  condition  is  consequently 
frequently  described  as  being  due  to  atrophy  of  the  optic  nerve.  The 
smaller  branches  are  often  completely  obliterated.  Schweigger*  has 
more  especially  pointed  out  this  fact,  and  considers  that  the  peculiar 
torpor  of  the  retina,  which  is  noticed  when  the  illumination  is  moderate, 
is  due  to  the  fact  that  on  account  of  the  diminution  in  the  calibre  of  the 
arteries  an  insufficient  amount  of  blood  is  supplied  to  the  retina.  At  a 
later  stage  of  the  disease,  atrophy  of  the  optic  nerve  and  of  the  retina 
almost  always  occur.  Changes  in  the  choroid  are  also  not  unfrequently 
met  with.  These  may  be  chiefly  confined  to  a  thinning  and  atrophy  of 
the  epitheUum  at  certain  points,  so  that  the  choroidal  vessels  become 
apparent,  and  are  seen  traversing  these  lighter  patches,  which  are  often 
fringed  by  a  dark  zone  of  pigment ;  or  the  stroma  of  the  choroid  may 
become  afiected,  and  if  it  be  much  thinned,  the  white  sclerotic  may  be 
seen  glistening  through  it.  In  such  cases  the  fundus  afibrds  a  very 
marked  and  striking  appearance,  being  marbled  with  more  or  less 
extensive,  reddish  grey,  or  greyish  white  glistening  patches,  in  the 
expanse  and  at  the  edge  of  which  are  agglomerations  of  pigment.  It  is 
now  no  longer  a  case  of  simple  retinitis  pigmentosa,  but  of  choroido- 
retinitis. 

At  a  later  stage  of  retinitis  pigmentosa,  we  often  find  that  an  opacity 

makes  its  appearance  at  the  posterior  pole  of  the  lens,  whichremains  either 

stationary  or  is  but  very  slowly  progressive.    The  retinitis  almost  always 

affects  both  eyes.     In  rare  instances  the  vitreous  humour  also  becomes 

*  Vorlcsungen  iiber  den  Aiigcnspiegel. 


RETINITIS   PIGMENTOSA.  351 

affected,  and  small  grey,  circumscribed  flakes  are  seen  floating  about  in 
it.  Externally  the  eyes  present  nothing  abnormal,  excepting  that  the 
pupil  is  generally  small,  and  the  anterior  chamber  somewhat  shallow. 

Great  diversity  of  opinion  still  prevails  as  to  the  formation  of  the 
pigment,  and  whether  it  is  primarily  developed  in  the  retina,  or  whether 
it  makes  its  way  into  the  latter  from  the  choroid.  Until  several  eyes,  in 
which  the  typical  form  of  retinitis  pigmentosa  has  been  diagnosed 
during  life  with  the  ophthalmoscope,  have  been  submitted  to  careful 
microscopical  examination,  this  cannot  be  decisively  settled.  At  present 
it  appears  certain  that  the  disease  may  arise  in  both  w^ays.  Thus 
Donders  found  that  the  pigment  may  be  developed  in  the  retina  itself, 
probably  in  consequence  of  a  chronic  inflammation  of  this  membrane. 
That  such  may  actually  be  the  case,  without  any  participation  of  the 
choroid,  is  also  proved  by  a  case  of  Schweigger's,*  in  which  he  found, 
on  microscopical  examination,  that  the  deposit  of  pigment  on  the  retinal 
vessels  may  occur  quite  independently  of  any  changes  of  the  choroid, 
for  in  this  case  the  choroidal  epithelium  was  perfectly  normal,  even  in 
spots  where  the  retina  was  pigmented.  The  pigmentation  was  con- 
fined to  the  retinal  vessels,  the  coats  of  which  were  thickened  and 
the  smaller  branches  obliterated,  these  changes  extending  beyond  the 
pig-mentation.  In  those  cases,  in  which  ii'regular  roundish  masses  of 
pigment  are  strewn  about  the  retina,  Schweigger  thinks  that  the  disease 
is  always  due  to  choroiditis,  and  that  the  deposits  of  pigment  partly 
become  developed  in  the  firm  exudations  which  have  forced  their 
way  into  the  retina  from  the  choroid,  or  are  due  to  the  fact  that  the  pro- 
liferating pigmentary  epithelial  cells  of  the  choroid  are  floated  into,  or 
grow  into  the  retina.  Junge  thinks  that  a  deposit  of  pigment  along 
the  retinal  vessels  can  only  take  place  in  the  retina  when  the  external 
layers  are  more  or  less  destroyed,  so  that  the  pigment  can  make  its  way 
from  the  choroid  into  the  retina. 

There  is,  moreover,  another  way  in  which  an  infiltration  of  pigment 
from  the  choroid  into  the  retina  may  occur,  for  an  accurate  knowledge 
of  which  we  are  chiefly  indebted  to  the  valuable  researches  of  H.  Miiller 
and  Pope.f  It  appears  that  a  proliferation  of  the  granular  cells  of  the 
retina  similar  to  that  in  nephritic  retinitis  may  take  place  independently, 
accompanied  by  hypertrophy  of  the  radiating  connective  tissue  fibres 
in  the  external  granular  layers,  which  become  bent  in  an  arcade-like 
manner.  The  baccillar  layer  of  the  retina  becomes  destroyed,  and  the 
hypertrophied  granular  layer  protrudes  above  the  external  layer  of  the 
retina  ;  between  these  protrusions  there  exist  corresponding  depressions, 
into  which  the  pigment  cells  of  the  epithelial  layer  of  the  choroid  become 
pushed  and  heaped  up  into  little  black  masses,  which  lend  a  peculiar 

*  Vorlesimgen,  p.  11.3. 

t  "  Wui-zb.  Med.  Zeitschrift,"  iii ;  also  "  Oph.  Hosp.  Eeports,"  iv,  p.  76. 


352  DISEASES  OF   THE  RETINA. 

marbled  appearance  to  the  retina.  It  is  doubtful,  however,  as  Schweigger 
points  out,  whether  this  morbid  process  yields  the  peculiar  ophthalmos- 
copic appearances  characteristic  of  retinitis  pigmentosa. 

The  most  striking  symptom  of  which  the  patients  complain  is  that 
of  hemeralopia,  or  night  blindness.  During  the  day,  or  in  a  bright 
illumination,  they  may  be  able  to  see  perfectly  well,  but  as  soon  as  it 
becomes  dark,  or  they  are  taken  into  a  dimly-lighted  room,  their 
sight  becomes  greatly  impaired.  I  need  hardly  point  out  that  this 
peculiar  impairment  of  vision  is  quite  independent  of  the  fact  whether 
it  be  night  or  day,  and  is  simply  due  to  the  retina  being  in  a  con- 
dition of  torpor,  which  demands  a  very  bright  illumination  in  order 
to  enable  it  to  distinguish  objects  which  a  healthy  eye  could  see  with 
ease,  even  by  a  moderate  amount  of  illumination.  This  torpor  of  the 
retina  is  in  all  probability  not  due  to  the  pigmentation  of  the  retina,  but, 
as  Schweigger  insists,  to  the  obliteration  of  the  i-etinal  vessels  or  the 
diminution  of  theii'  calibre  through  hypertrophy  of  their  coats,  so  that 
the  retina  obtains  a  diminished  and  insufficient  supply  of  blood.  The 
truth  of  this  opinion  is  proved  by  the  fact,  that  Schweigger  has  noticed 
the  presence  of  hemeralopia  and  contraction  of  the  field  of  vision  in 
children  before  the  appearance  of  any  pigment  in  the  retina ;  but  in  all 
these  cases  there  was  a  marked  contraction  of  the  retinal  arteries,  whilst 
the  older  brothers  and  sisters  had  retinitis  pigmentosa.  He  also 
observed  this,  in  some  rare  instances,  in  older  persons  (between  the  age 
of  40  and  50),  who  suffered  from  all  the  symptoms  of  retinitis  pigmen- 
tosa, e.g.,  hemeralopia  from  torpor  of  the  retina,  great  contraction  of 
the  visual  field,  without  any  trace  of  pigmentation  of  the  retina  or  any 
other  symptom  except  contraction  of  the  arteries  and  paleness  of  the 
disc.  In  similar  cases  Von  Graefe  has  subsequently  found  a  deposit 
of  pigment  in  the  retina. 

The  field  of  vision  is  often  very  greatly  conti'acted  in  cases  of 
retinitis  pigmentosa,  so  that  there  may  only  be  a  very  small  portion 
remaining,  the  diameter  of  which  perhaps  only  measures  a  few  inches ; 
whilst  the  sight  in  the  optic  axis  may  yet  be  excellent,  enabling  the 
patient  to  read  the  very  finest  print,  although  all  around  him  is 
shrouded  in  darkness.  On  account  of  the  considerable  contraction  of 
the  field,  these  patients  acquire  a  very  awkward  and  restless  appearance, 
for  their  eyes  are  always  turned  slowly  about  in  various  dii'ections,  so 
as  to  bring  the  optic  axis  to  bear  upon  surrounding  objects,  which  they 
would  otherwise  not  perceive  or  stumble  over.  They  therefore 
experience  great  difficulty  and  danger  in  passing  along  a  crowded 
thoroughfare,  and  still  more  in  crossing  the  street,  as,  although  they 
may  see  well  straight  before  them,  they  cannot  distinguish  anything 
that  lies  in  the  lateral  portions  of  the  field. 

As  long  as  the  region  of  the  yellow  spot  remains  unimpaii-ed  the 


DETACHMENT   OF   THE   RETINA.  353 

siglit  may  remain  good,  but  between  tlie  ages  of  35  and  50  the  disease 
almost  invariably  leads  to  complete  blindness,  the  retina  and  optic  nerve 
becoming  atrophied.  Retinitis  pigmentosa  almost  invariably  occurs  in 
both  eyes.  Padraglia  mentions  a  case  in  which  it  affected  only  one  eye, 
as  1  have  also  met  with  one  amongst  my  patients  at  Moorfields.  The 
disease  is  very  frequently  congenital  and  also  hereditary.  Although  it 
may  be  present  at  birth,  it  always  slowly  and  gradually  increases  in 
extent  with  advancing  years.  Schweigger  has  noticed  that  the  pig- 
mentation of  the  retina  is  not  only  j^receded  by  contraction  of  the 
arteries,  but  also  by  small  light  coloured  dots  or  faint  stripes  in  the 
choroid.  The  disease  may  first  show  itself  about  the  age  of  8  or  10, 
or  even  later  in  life,  at- 30  or  40.  It  frequently  occurs  in  several 
members  of  the  same  family,  and  is  then  often  hereditary.  Such  cases 
are  mentioned  amongst  others  by  Laurence,  Mooren,  and  Hutchinson. 
Laui'ence*  met  with  it  in  four  members  of  the  same  family  (of  eight)  ; 
in  this  case  it  was  not  hereditary.  Mooren  has  also  seen  it  in  four 
persons  of  the  same  family.  Liebreich  has  pointed  out  the  important 
fact  that  it  occurs  very  frequently  in  marriages  of  consanguinity,  and 
often  together  with  deaf-mutism.  Other  malformations — such  as  super- 
numerary fingers  and  toes,  are  also  sometimes  seen  together  with  reti- 
nitis pigmentosa. 

The  prognosis  is,  of  course,  very  unfavourable,  as  these  cases 
always  end  sooner  or  later  in  total  blindness.  With  regard  to  treat- 
ment, I  can  only  recommend  care  of  the  eyes,  more  especially  against 
bright  glare  and  over  work,  and  attention  to  the  general  health. 
Occasionally  some  temporary  improvement  of  the  central  vision  has 
taken  place  after  the  application  of  the  artificial  leech,  and  the  admi- 
nistration of  bichloride  of  mercury,  iodide  of  potassium,  etc.,  but  it 
has  been  noticed  in  some  of  these  cases,  that  this  improvement  has  been 
followed  by  a  marked  and  rapid  deterioration  of  the  field  of  vision. — • 
(Mooren). 


8.— DETACHMENT  OF  THE  RETINA  (Plate  V.,  Fig.  10). 

If  the  detachment  of  the  retina  from  the  choroid  is  very  extensive 
and  reaches  far  into  the  vitreous  humour,  the  symptoms  presented  by  it 
are  so  marked  and  characteristic  that  it  may  sometimes  be  recognised 
with  the  naked  eye,  but  certainly  with  the  greatest  ease  by  the  aid  of 
the  ophthalmoscope.  On  examining  in  the  du'ect  method  an  eye 
afiiected  with  an  extensive  detachment  of  the  lower  half  of  the  retina, 
we  at  once  notice  that,  when  it  is  moved  in  different  directions,  we  gain 

*  "  Ophthalmic  Review,"  vol.  ii,  32. 

2   A 


o54  DISEASES   OF   THE   RETINA. 

tlie  usual  bright  red  reflex  from  the  upper  part  of  the  fundus,  but  that 
in  the  lower  half  this  is  not  the  case.  Here,  on  the  other  hand,  the 
reflex  has  a  bluish-grey  or  greenish  tint,  and  on  closer  inspection  we 
observe  a  bluish-grey,  floating,  wavelike  opacity,  which  is  thrown  into 
marked  undulating  folds  with  every  movement  of  the  eye,  and  which 
is  traversed  by  dark,  crooked,  and  distorted  vessels.  On  account  of 
the  bulging  forward  of  the  detached  retina  into  the  vitreous,  these 
details  can  be  readily  seen  with  the  direct  examination  at  some  little 
distance  from  the  eye.  The  detached  retina  also  reflects  the  light  very 
strongly,  which  is  chiefly  due  to  the  diflerence  between  the  colour  and 
refracting  power  of  the  fluid  situated  between  the  retina  and  choroid  and 
those  of  the  vitreous  humour.  The  minute  details  may  be  examiued 
either  in  the  erect  or  reverse  image,  and  the  extent  of  the  detachment, 
as  well  as  the  coiirse  and  displacement  of  the  vessels,  should  be  carefully 
studied.  It  will  be  noticed  that  the  vessels  are  darker  than  on  the 
normal  retina,  and  that  they  are  very  crooked  and  tortuous,  riding,  so  to 
speak,  on  the  folds  of  the  retina,  between  which  they  may  even  be  com- 
pletely hidden  for  a  part  of  their  course.  With  every  movement  of  the 
eye  they,  as  well  as  the  undulating  grey  folds  of  retina,  quiver  and 
tremble.  On  tracing  out  the  limits  of  the  detached  portion,  we  gener- 
ally find  that,  even  beyond  its  marked  commencement,  there  is  a  faint 
greyish  opacity  or  thickened  appearance  of  the  retina,  and  that  the  vessels 
are  somewhat  darker,  and  show  a  slight  tendency  to  be  curved.  This 
opacity  of  the  retina  is  due  to  serous  infiltration.  If  the  detached  fold 
of  retina  is  large  and  prominent,  it  throws  a  distinct  dark  line  of  shadow 
upon  the  neighbouring  fundus. 

Whilst  little  or  no  difiiculty  can  be  experienced  in  recognising  a 
considerable  detachment  of  the  retina,  the  same  cannot  always  be  said 
of  the  slighter  degrees,  the  diagnosis  of  which  often  demands  con- 
siderable dexterity  and  experience  on  the  part  of  the  observer.  This  is 
more  especially  the  case  if  the  subretinal  fluid  is  transparent,  and  the 
vitreous  humour  is  somewhat  clouded.  Sometimes,  it  is  only  by  tracing 
out  most  carefully  and  with  the  greatest  exactitude,  the  course  of  each 
individual  retinal  vessel  from  the  optic  disc  towards  the  periphery  of  the 
fundus,  that  we  are  enabled  to  detect  a  very  sHght  degree  of  detachment. 
In  such  a  case,  we  notice  that  as  the  vessels  reach  the  detached  portion 
(which  is  generally  somewhat  opaque  and  thickened  looking,  or  thrown 
into  a  slight  fold),  they  assume  a  darker  tint,  and  instead  of  preserving 
a  straight  course,  they  become  tortuous  and  bent,  forming  a  more  or  less 
marked  deflection. 

On  close  examination,  we  also  notice  that  the  vessels  lie  on  a  dif- 
ferent level  to  those  which  retain,  their  normal  position,  being  closer  to 
the  observer,  who  has  consequently  slightly  to  alter  his  accommodation 
in  order  to  obtain  as  distinct  an  image  of  them.     Indeed  the  apprecia- 


DETACHMENT   OF   THE   RETINA.  355 

tion  of  this  diifereiice  iii  the  plane  of  the  vessels,  is  one  of  the  most 
delicate  aids  in  the  diagnosis  of  commencing  detachment  of  the  retina. 
We  can,  moreover,  detect  a  well-marked  parallax ;  for  if  we  make  a 
lateral  movement  with  the  object  lens,  the  portion  of  the  vessel  which 
is  elevated  by  the  detached  retina,  will  be  seen  to  make  a  greater  move- 
ment than  that  part  which  lies  in  the  normal  retina.  The  detached 
portion  of  retina  also  reflects  the  Ught  more  strongly,  which  is  espe- 
cially appreciable  in  the  direct  examination. 

On  tracing  the  course  of  the  vessels  further,  we  often  find  that  as 
we  approach  the  periphery  of  the  fundus,  the  detachment  becomes 
more  conspicuous  and  extensive,  the  retina  being,  perhaps,  near  the 
equator  of  the  eye,  thrown  into  distinct  whitish-grey  folds.  In  the 
portion  of  retina  Avhich  is  still  in  situ  and  in  close  proximity  to  the 
detachment,  we  may  sometimes  notice  small,  reddish- white  exudations, 
and  also,  as  was  especially  pointed  out  by  Von  Graefe,*  small,  red, 
isolated  patches,  which  are  made  up  of  minutely  coiled  blood-vessels. 
Small  partial  detachments  of  the  retina  are  often  difficult  to  recognise, 
as  they  may  simply  appear  in  the  form  of  little,  faint,  grey  streaks. 
These  details  are  best  appreciated  with  the  binocular  ophthalmoscope. 
The  colour  of  the  detachment  depends  chiefly  ripon  that  of  the  fluid 
which  Hes  beneath  it;  at  first,  the  detached  portion  of  retina  is  generally 
transparent,  but  at  a  later  period  it  becomes  more  or  less  opaque  and 
clouded.  This  may,  however,  be  the  case  from  the  commencement,  if 
the  detachment  supervenes  upon  inflammation  of  the  retina.  The 
sub-retinal  fluid  also  varies  considerably  in  composition.  When  recent, 
it  is  ti-ans  parent,  or  of  a  faint  straw  colour,  and  of  a  serous  nature, 
containing  a  good  deal  of  albumen  (Bowman), f  which  coagulates  on 
exposure  to  heat,  or  may  even  do  so  in  the  eye,  and  then  it  becomes 
adherent  to  the  walls  of  the  detached  retina  in  the  form  of  opaque 
flakes  (Liebreich).  It  may  also  contain  blood,  fibrin,  nuclei,  pigment 
and  fat  molecules,  or  cholesterine. 

The  detachment  most  frequently  occupies  the  lower  portion  of  the 
fundus,  and  its  extent  varies  considerably.  It  may  for  some  time 
remain  confined  to  the  periphery  of  the  fundus,  and  then  gradually 
extend  further  and  further,  until  it  reaches  the  optic  nerve,  and  thus 
involves  the  whole  of  the  lower  half  of  the  retina.  It  often,  also, 
mounts  up  somewhat  on  one  or  both  sides  of  the  disc.  When 
the  detachment  occurs  in  the  upper  portion  of  the  retina,  it  soon 
extends  from  thence  downwards,  which  is  due  to  the  gravitation  of  the 
fluid,  and  in  such  a  case  the  greater  portion  of  the  retina  may  become 
detached  all  round  the  optic  disc,  forming  a  funnel-shaped  detachment, 
whose  apex  is  at  the  optic  nerve.     But  we  may  sometimes  also  observe 

*  "  A.  f.  O.,"  i,  1,  367. 

t  Bowman,  "  Ophthalmic  Hospital  Reports,"  vol.  iv,  p.  136.     1864. 

2  A  2 


356  DISEASES   OF   THE   RETINA. 

that  as  tlie  fluid  gravitates  downwards,  the  upper  portions  of  the  retina 
fall  again  into  apposition  with  the  choroid,  regaining  perhaps  a  con- 
siderable or  even  normal  degree  of  transparency ;  this  being,  moreover, 
accompanied  by  a  great  improvement  of  vision.  This,  I  may  state,  in 
passing,  is  a  most  important  point  with  regard  to  the  indications  of 
treatment. 

Sometimes,  if  the  retina  has  been  tensely  stretched  by  the  fluid 
oeneath  it,  a  rent  may  occur  in  it,  and  we  can  then  observe  with  the 
Dphthalmoscope  that  there  exists  a  gap,  within  which  the  vessels  and 
intra- vascular  spaces  of  the  choroid  are  distinctly  apparent  ;*  the  edges 
of  the  torn  retina  being  curled  or  rolled  up  into  little  folds. 

The  first  symptom  which  the  patient  generally  notices  is  that  of  a 
faint  grey  cloud  floating  before  him,  or  of  a  dark  spot,  surrounded  by  a 
lighter  halo.     This  cloud  has  a  wavy,  indistinct  outline,  and  its  position 
in  the  field  of  vision  corresponds  accurately  with  the  situation  of  the 
detached  portion  of  retina.     Thus,  if  the  detachment  be  situated  at  the 
lower  part  of  the  retina,  the  patient  notices  a  httle  cloud  or  curtain 
hanging  down  into  the  upper  part  of  the  visual  field,  like  the  edge  of  a 
veil,  or  peak  of  a  cap.     He  also  notices  that  linear  objects,  instead  of 
preserving  a  straight  outline,  appear  to  be  wavy  and  broken.     This 
nietamorphopsia  is  probably  due  to  a  change  in  the  normal  position  of 
the  nerve   elements  of  the  retina  in  the  close  vicinity  of  the  detach- 
ment, this  displacement  being,  perhaps,  caused  by  a  slight  di^agging 
upon  that  portion  of  the  retina  which  is  no  longer  in  situ.     Knappf 
points  out  that  the  metamorphopsia  due  to  detachment  of  the  retina,  is 
distinguished  by  the  fact,  that  the  objects  are  fringed  with  a  coloured 
ring,    and  undergo    slight  undulating  movements.      Sometimes,   this 
metamorphopsia  is  the  principal  symptom  which  leads  us  to  detect  a 
small  cii'cumscribed  detachment  of  the  retina.     The  patients  also  often 
complain  of  bright  flashes  of  light,  bright  circles  or  stars,  etc.,  these 
photopsies  being  due  to  the  irritation  and  stretching  of  the  retina,  pro- 
duced by  the  change  in  its  position.     The  black  spots  and  flakes  which 
float  about  in  the  field  of  vision,  assiuning  various  peculiar  forms,  are 
caused  by  opacities  in  the  vitreous  humour,  which  are  very  frequently 
met  with  in  detachment  of  the  retina,  and  may  even  be  the  cause  of  it. 
On  examining  the  field  of  vision,  we  find  a  more  or  less  marked 
impairment  and  contraction  of  certain  portions  of  it,  which  correspond 
to  the  situation  of  the  detachment.     Thus,  if  the  latter  has  occurred 
below,  the  upper  portion  of  the  field  will  be  impaired,  and  vice  versa. 
If  the   detachment  is  very  irregular  in  its  outline,  the  field  presents 
corresponding  irregularities,  the  outline  of  the  defective  portion  rising 
and  falling  according  to  the  rise  and  fall  of  the  detachment.     We  find 

*  Vide  Liebrcii'h's  Atlas,  Plate  VII,  Fig.  1. 
+  "  Kliuisolic  MunatsbliiUer,"  18Gi,  p.  3U7. 


DETACHMENT   OF   THE   RETINA.  357 

that  the  field  of  vision  is  contracted  not  only  qnantitatively,  but  also 
qualitatively ;  although  there  is  no  doubt  that  the  retina,  even  when 
actually  raised  by  fluid  from  the  choroid,  may  retain  a  certain  degree  of 
perceptive  power,  the  patient  being  able  to  tell  the  movements  of  the 
hand  or  even  to  count  fingers. 

The  indistinctness  or  contraction  of  a  certain  portion  of  the  visual 
field  is  also  seen  occasionally  to  precede  the  detachment  of  the  retina, 
and  is,  therefore,  of  great  prognostic  importance.  Thus,  in  cases  of 
extensive  sclerectasia  posterior,  we  may  sometimes  detect  a  marked  con- 
traction of  the  field  in  a  certain  dii'ection  (say  upwards,  or  upwards  and 
inwards),  but  the  most  careful  and  accurate  ophthalmoscopic  examina- 
tion ^vill  fail  to  discover  any  detachment.  But  some  time  afterwards 
this  may  occur,  and  at  a  point  of  the  retina  corresponding  to  that  portion 
of  the  field  which  was  defective. 

The  causes  of  detachment  are  numerous,  and  sometimes  obscure. 
It  may  be  produced  by  blows  upon  the  eye,  or  by  penetrating  wounds 
of  the  posterior  portion  of  the  eyeball,  in  which  case  there  is  often  a 
cicatricial  contraction  of  the  retina ;  also  by  efiusions  of  blood  or  serum 
between  the  retina  and  choroid.  In  such  a  case,  the  hsemorrhagfe 
generally  occurs  fi'om  the  choroid,  on  account  of  the  greater  vasciilarity 
of  this  membrane.  Wlien  speaking  of  hajmorrhage  into  the  vitreous 
humour  (p.  316),  it  was  mentioned  that  when  the  bleeding  occurs  in  the 
central  portion  of  the  fundus,  it  is  prone  to  lead  to  detachment  of  the 
retina,  whereas,  in  the  equatorial  region  it  is  more  apt  to  break  through 
into  the  vitreous  humour.  But  haemorrhage  fi'om  the  retina  itself,  by 
making  its  way  outwards  between  the  choroid  and  retina,  may  lead  to  a 
detachment  of  the  latter. 

The  serous  effusion  between  the  retina  and  choroid  which  produces 
the  detachment,  may  be  the  product  of  inflammatory  lesions  of  these 
tunics,  or  may  be  due  to  a  sudden  compression  of  the  vessels  of  the 
eye  and  an  impediment  of  the  venous  reflux,  as  for  instance  in  cases  of 
exophthalmos  due  to  intra-orbital  tumours,  etc. 

The  most  frequent  cause  is  undoubtedly  an  elongation  of  the  optic 
axis,  as  in  cases  of  sclerectasia  posterior,  for  the  elongation  of  the 
sclerotic  is  accompanied  by  a  corresponding  stretching  of  the  cho- 
roid and  retina.  The  forraer,  on  account  of  its  firm  union  with  the 
sclerotic,  and  its  greater  elasticity,  follows  this  gi'adual  distension,  but 
the  retina  is  less  elastic,  and  will  therefore  have  a  greater  difiiculty  in 
.following  the  traction  of  the  sclerotic  and  choroid  ;  its  connection  with 
the  latter  will  be  rendered  lax,  and  any  slight  efiusion  or  exudation 
from  the  choroid  will  sufiice  to  produce  an  extensive  detachment. 
Such  effusions  are  the  more  likely  to  occur  in  these  advanced  cases 
of  sclerectasia  posterior,  as  there  is  generally  some  choroiditis  present, 
or  a  disturbance  of  the  intra-ocular  circulation. 


358  DISEASES   OF   THE   RETINA. 

A  cysticercus,  making  its  way  through  into  the  vitreous  humour 
may  give  rise  to  a  considerable  detachment  of  the  retina,  which  will  be 
tense,  and  not  undulating  or  falling  into  folds.  It  may  also  be  pro- 
duced by  a  tumour  springing  from  the  choroid,  and  here  the  early 
diagnosis  of  the  cause  of  the  detachment  is  of  much  consequence. 
This  may  be  difB.cult  when  the  tumour  is  small,  as  the  detachment 
may  then  be  loose  and  undulating,  whereas,  when  it  increases  in  size, 
and  protrudes  more  into  the  vitreous  humour,  the  retina  may  be 
stretched  tensely  over  it,  and  not  fall  into  wrinkles  or  folds  ;  or  distinct 
nodules,  perhaps  of  a  dark  pigmented  appearance,  are  seen  stretching 
out  the  detached  retina  here  and  there.  The  diagnosis  of  a  tumour 
is  still  more  strengthened,  if,  with  the  increase  in  the  size  of  these 
nodules,  the  eye  tension  progressively  augments  (Graefe).*  Indeed  the 
tension  of  the  eyeball  is  of  great  importance  in  the  diiferential  diagnosis 
between  a  simple  detachment  of  the  retina,  and  one  produced  by 
a  subretinal  tumour.  In  the  former  case,  the  eye-tension  is  almost 
always  decidedly  diminished,  whereas  the  reverse  obtains  in  cases  of 
intra-ocular  tumour,  the  tension  being  either  normal,  or,  as  the  growth 
advances,  markedly  augmented.  Bowman, f  has,  however,  in  a  few 
rare  instances  met  with  a  tendency  to  increased  tension  in  cases  of 
simple  detachment  of  the  retina. 

The  retina  may  also  be  detached  by  traction  from  in  front,  through 
the  contraction  and  shrivelling  up  of  opacities  in  the  vitreous  humour, 
which  are  by  one  extremity  attached  to  the  retina.  In  contracting, 
they  di-aw  the  latter  from  the  choroid,  its  connection  with  which  is 
often  already  but  very  slight,  as  for  instance  in  cases  of  sclerotico- 
choroiditis  posterior. 

The  prognosis  of  detachment  of  the  retina  is  unfavourable.  In 
some  very  rare  instances,  the  disease  may  remain  stationary  at  an 
early  stage,  and  whilst  the  detachment  is  still  but  inconsiderable. 
Or  the  detachment  may  even  disappear,  the  subretinal  fluid  having 
become  absorbed,  or  penetrated  into  the  vitreous  humoiir  after  a  spon- 
taneous rupture  of  the  retina.  In  such  cases,  the  retina  is  re-applied  to 
the  choroid,  and  may  regain  its  functions,  even  after  the  detachment  has 
lasted  for  some  time,  for  the  rods  and  bulbs  retain  their  anatomical 
characters  for  a  long  time.  Such  cases  are,  however,  very  rare.  One 
is  described  by  Von  Graefe,  in  which  the  detachment  occurred  in 
consequence  of  an  orbital  abscess,  and  where  after  the  escape  of  the 
discharge,  the  retina  became  re-attached  to  the  choroid,  and  the  sight 
restored.  J     A  similar  case  is  recorded  by  Dr.  Berlin.  § 

Mr.  Bowman  has  also   mentioned  a  case  to  me,  in  which  he  has 

*  "  Arch.  f.  Ophth.,"  xii,  2,  239.  t  "  Oplithal.  Hosp.  Ecporis,"  iv,  134. 

X  "  Klin.  Monatsblatter,"  1863,  p.  49.        §  Ibid.,  18G6,  p.  77. 


DETACHJIENT   OP   THE   RETINA.  359 

observed  the  total  spontaneous  disappearance  of  a  considerable  detach- 
ment. Other  cases  have  been  narrated  by  Liebreich,  Galezowski, 
Steffan,  etc. 

But  in  the  great  majority  of  cases  the  natiiral  course  of  the  disease 
is  slowly,  but  surely  progressive,  leading  finally  to  total  blindness, 
sometimes  in  consequence  of  irido-choroiditis  and  atrophy  of  the  globe. 
Although  the  detachment  generally  remains  confined  to  one  eye,  it  may 
extend  to  the  other,  and  this  is  to  be  especially  feared,  if  the  same  cause 
exists  in  the  latter,  e.g.,  extensive  sclerectasia  posterior. 

Until  the  last  few  years,  the  treatment  has  been  entirely  directed 
towards  endeavouring  to  procure  the  absorption  of  the  subretinal  fluid, 
or  to  prevent  and  retard  the  progress  of  the  detachment.  The  chief 
remedies  that  were  employed  for  this  purpose  were  derivatives,  mer- 
cury, the  application  of  the  artificial  leech,  etc.  The  patients  being 
at  the  same  time  strictly  ordered  to  abstain  from  all  employment 
that  necessitates  any  prolonged  efibrt  of  the  accommodation,  or  that 
might  produce  congestion  of  the  eye  or  head.  The  results,  however, 
of  this  mode  of  treatment  were  not  favourable,  and  only  in  very 
rare  instances  did  the  detachment  disappear.  I  must  confess  that  I 
have  never  succeeded  in  achieving  this  result  by  medicinal  means, 
although  I  have  been  sometimes  able  to  retard  the  progress  of  the 
disease  by  suitable  treatment,  together  with  complete  rest  of  the  eyes, 
and  the  occasional  and  guarded  application  of  the  artificial  leech.  The 
latter  should,  however,  be  employed  vpith  extreme  care,  as  its  applica- 
tion is  always  followed  by  a  certain  degree  of  intra-ocular  hyperaemia, 
which  might  easily  tend  to  increase  the  detachment.  For  this  reason, 
I  often  prefer  dry  cupping  at  the  temple  or  the  back  of  the  neck,  more 
especially  in  those  cases  in  which  the  hypertemia  might  prove  par- 
ticularly dangerous,  e.g.,  sclerectasia  posterior  accompanied  by  marked 
symptoms  of  congestion  and  vascular  excitement. 

The  fact  that  the  absorption  or  gravitation  of  the  subretinal  fluid,  or 
its  escape  into  the  vitreous  after  spontaneous  rupture  of  the  retina,  is 
followed  by  a  marked  return  of  sensibility  in  the  re-attached  retina,  has 
led  some  of  the  most  distinguished  ophthalmologists,  especially  Bowman 
and  Graefe,  to  endeavour  to  gain  a  similar  favourable  result  by  opera- 
tive treatment,  by  dividing  the  retina  and  permitting  the  fluid  to  escape 
-into  the  vitreous  humour. 

Von  Graefe,*  in  order  to  gain  this  end,  divides  the  retina  with  a 
peculiar  cutting-needle,  having  two  sharp  edges.  The  eye  being 
steadied  with  a  pair  of  forceps,  he  enters  the  needle  in  the  sclerotic 
about  4 — 5  lines  frora  the  edge  of  the  cornea,  and  in  the  meridian  corre- 
sponding to  the  most  prominent  part  of  the  detachment,  and  if  the 

*  "  Archiv.  f.  Ophthalm.,"  ix,  2,  85  ;  vide  also  Mr.  Roger's  able  translation  of 
this  Article  in  "  Ophthal,  Hosp.  Rep.,"  vol.  iv,  p.  213. 


360  DISEASES   OP   THE   RETINA. 

situation  of  the  latter  permits  it,  the  puncture  should  be  made  in  the 
outer  hemisphere.  The  needle  should  be  passed  perpendicularly  behind 
the  lens  into  the  vitreous  chamber  for  about  6  Hues,  and  then,  the  apex 
being  turned  by  a  simple  lever  movement  towards  the  fundus,  the  one 
edge  is  to  be  pressed  against  the  retina.  This  movement  is  to  be  con- 
tinued whilst  the  needle  is  simultaneously  withdrawn.  By  the  latter 
retracting  incision,  the  continuity  of  the  prominent  retina  is  to  be 
divided.  Care  must  be  taken  not  to  bring  the  point  of  the  needle  in 
contact  with  the  choroid. 

Mr.  Bowman  states  that  his  object  in  operating  in  detachment  of  the 
retina  "  has  never  been  to  give  external  vent  to  fluid,  though  this  has 
almost  always  been  one  immediate  effect  of  my  punctures,  but  rather 
to  open  a  permanent  communication  inwards  from  the  subretinal  space, 
under  the  idea  of  allowing  the  effused  fluid  to  escape  into  the  vitreous 
chamber,  rather  than  to  spread  further  between  the  retina  and  choroid, 
thereby  further  severing  their  organic  connection.  So  slight  is  this 
connection  that  fluid  effused  at  one  part  easily  gravitates  to  another 
more  dependent  part."*  At  first  Mr.  Bowman  only  used  one  needle, 
simply  puncturing  the  retina  through  the  sclerotic,  but  he  now 
employs  two,  dilacerating  the  retina  in  a  manner  similar  to  that  in  his 
double  needle  operation  for  opaque  capsule.  This  operation  is  per- 
formed in  the  following  manner  : — The  lids  are  to  be  kept  apart  with 
the  spring  speculum,  and  the  eye,  if  necessary,  fixed  with  a  pair  of 
forceps.  The  needles,  which  should  have  a  fine  lancet  point,  are  then 
to  be  introduced  separately  through  the  sclerotic  at  a  short  distance 
from  each  other,  and  at  a  point  corresponding  to  the  most  prominent 
part  of  the  detachment ;  the  points  are  then  directed  towards  each  other 
so  that  they  may  pierce  the  retina  at  the  same  spot ;  by  then  separating 
their  points  the  retina  is  torn  between  them  (as  in  Fig.  54).  Generally 
a  little  oozing  of  the  subretinal  fluid  takes  place 
under  the  conjunctiva,  indeed  it  may  even  give 
rise  to  a  small  elevation.  The  vitreous  often  be- 
comes somewhat  turbid  after  the  operation,  but  soon 
clears  again,  and  then  the  small  tear  in  the  retina 
may  sometimes  be  detected.  The  points  of  punc- 
ture of  the  sclerotic  must  vary  of  course  with  the 
position  and  extent  of  the  detachment,  but  they 
will  generally  lie  from  J  to  A-  an  inch  from  the 
margin  of  the  cornea,  and  between  the  tendons  of  the  recti  muscles. 
As  the  operation  gives  but  little  pain,  chloroform  need  not,  as  a  rule, 
be  administered.  The  operation  is  generally  followed  by  some,  often 
by  very  considerable  improvement  of  the  sight  and  the  state  of  the 

*  Vide  Mr.  Bowman's  very  interesting  Article,  "  On  Needle  Operations  in  cases 
of  Detached  Ectina,"  "Ophth.  Hosp.  Ecports,"  iv,  134. 


EPILEPSY   OF   THE   RETINA.  361 

field  of  vision.  It  is  true  that  this  improvement  is  mostly  but 
temporary,  and  that  the  operation  may  have  to  be  repeated  several 
times,  each  repetition  being  again  followed  by  a  diminution  of  the 
detachment  and  amelioration  of  the  sight ;  such  repetitions  should  not, 
however,  follow  too  closely  upon  each  other,  otherwise  serious  irrita- 
tion of  the  eye  may  be  set  up.  I  have  seen  instances  in  which  the 
improvement  after  one  operation  has  lasted  for  many  months,  and 
Bowman  and  Graefe  have  observed  cases  in  which  it  has  been  maintained 
for  about  two  years.  Arlt*  mentions  one  in  which  the  cure  still  con- 
tinued 14  months  after  the  operation. 

The  operation  is  free  from  danger,  and  is  generally  followed  by  but 
slight  symptoms  of  irritation. 

If  we  consider  the  striking  results  often  obtained  by  it,  and  compare 
these  with  the  want  of  success  accompanying  the  former  plan  of 
treatment,  it  must  be  conceded,  I  think,  that  its  adoption  is  to  be 
strongly  recommended.  From  my  own  favourable  experience  of  its 
results  I  have  no  hesitation  in  speaking  strongly  in  its  favour.  We 
should,  however,  be  carefal  distinctly  to  warn  oui*  patients  that  the 
effect  may  only  be  slight  and  temporary.  The  operation  should,  if 
possible,  be  done  at  an  early  stage,  so  as  to  limit  the  extent  of  the 
detachment,  and  prevent  the  risk  of  the  retina  undergoing  organic 
changes,  leading  to  the  permanent  impairment  of  its  perceptive  func- 
tions. For  a  more  complete  exposition  of  these  points  I  must  refer  to 
the  articles  of  Bowman  and  Von  Graefe  already  quoted. 

I  should  mention  that  Weaker  employs  a  small  trocar  for  punc- 
turing the  retina,  which  he  enters  from  the  opposite  side  of  the  eye, 
and,  after  withdrawing  the  subretinal  fluid,  tears  the  retina  in  removing 
the  instrument. 

9.— EPILEPSY  OF  THE  RETINA. 

Dr.  Hughlings  Jackson  has  described  a  very  peculiar  condition  of 
the  retina  met  with  during  the  epileptic  fit,  and  has  given  to  it  the 
name  of  epilepsy  of  the  retina.  With  regard  to  it  he  says  :t — "  In  one 
case,  however,  a  case  of '  epileptiform  convulsions,'  I  had  the  oppor- 
tunity of  examining  the  fundus  of  the  eye,  if  not  during  a  genuine  fit, 
at  least  during  a  condition  in  which  consciousness  was  lost,  and  in 
which  the  pupils,  ordinarily  small,  were  dilated  as  if  under  the 
influence  of  atropine.  The  optic  discs  were  extremely  pale.  Once  the 
vessels  disappeared  for  an  appreciable  time.  After  a  while,  however, 
they  reappeared  and  were  found  to  vary  with  the  respiration.  When 
the   patient   in-spired   the   vessels   disappeared,    returning   again   on 

*  "Bericht  der  Wiener  Augenklinik.,"  1867,  85. 
t  "  Ophth.  flosp.  Reports,"  iv,  p.  14. 


302  DISEASES  OF  THE  RETINA. 

expiration,  like  lines  of  red  ink  on  white  paper."  It  appears  to  be  a 
temporary  complete  anemic  condition  of  the  retina,  dependent  in  all 
probability  upon  a  contraction  of  the  retraal  vessels,  just  as  the  un- 
consciousness occurring  during  the  epileptic  fit  is,  according  to  Brown- 
Sequard,  due  to  a  contraction  of  the  vessels  of  the  brain,  and  consequent 
anagmia  of  the  latter. 


10.— ISCHEMIA  RETINA. 

In  this  affection  the  retina  is  also  extremely  aneemic,  the  arteries 
being  greatly  attenuated  and  almost  bloodless,  the  veins  hyperaemic, 
but  irregularly  filled,  the  optic  disc  either  normal  or  but  slightly  pale, 
with  its  edges  perhaps  faintly  indistinct,  the  tension  normal  and 
dioptric  media  clear.  The  blindness  comes  on  very  suddenly,  affects 
both  eyes,  and  is  complete.  Such  at  least  were  the  principal  symptoms 
in  cases  of  this  very  rare  affection  recorded  by  Alfred  Graefe,*  Roth- 
niund,t  and  HeddausJ.  In  Graefe's  case  the  patient,  a  little  girl  6|- 
years  of  age,  suddenly  overnight  became  totally  blind  in  both  eyes,  so 
that  not  the  faintest  perception  of  hght  remained.  On  examination, 
the  eyes  presented  the  following  appearances  : — The  tension  of  the  eyes 
normal,  conjunctivae  very  pale,  the  eyeballs  of  marble  whiteness,  pupils 
much  dilated,  without  any  reaction  on  the  stimulus  of  light,  but  a  faint 
uniform  contraction  on  the  application  of  laudanum,  only  slight  increase 
in  dilatation  on  the  application  of  atropine.  With  the  ophthalmoscope, 
the  dioptric  media  were  found  transparent,  the  retinal  arteries  extremely 
attenuated,  the  veins  tortuous  and  dilated,  but  irregularly  so.  The 
retina  and  optic  nerve  were  normal,  the  outline  of  the  latter  being,  how- 
ever, very  slightly  indistinct. 

The  colour  of  the  skin,  but  especially  of  the  mucous  membranes, 
was  extremely  pale.  The  child  was  otherwise  perfectly  well ;  the  only 
peculiar  symptoms  being  the  extreme  rapidity  of  the  piilse,  which  was 
very  small,  and  numbered  160  beats  in  the  minute.  Graefe  considered 
that  the  probable  cause  of  the  blindness  was  an  insufficient  supply 
of  blood  to  the  retina,  the  faint  and  rapid  contractions  of  the  heart 
not  being  sufficient  to  overcome  the  normal,  but  proportionately  too 
considerable,  intra-ocular  tension ;  he  therefore  gave  the  name  of 
"  isclieemia  retinae  "  to  this  affection.  The  correctness  of  this  view  of 
the  cause  is  strengthened  by  the  fact  that,  after  all  other  remedies,  such 
as  mercury,  suppurating  blisters  behind  the  ears,  artificial  leeches  to 
the  temple,  etc.,  had  failed,  an  iridectomy,  made  upon  the  right  eye 

*  "  Archiv.  f.  Oplifhalm.,"  viii,  1,  143. 
t  "  Klin.  Monatsb."  1866,  p.  106. 
X  lb.,  1865,  p.  285. 


EMBOLISM   OF   THE   CENTRAL   ARTERY   OF   THE   RETINA.      363 

ten  days  after  the  complete  loss  of  sight,  proved  successful.  The 
object  in  performing  this  operation  was  to  diminish  the  intra-ocnlar 
tension,  and  thus  to  obtain  mechanically  a  greater  filling  of  the  vessels 
ex  vacuo.  Paracentesis  was  performed  on  the  left  eye.  The  effect  was 
most  marked  and  interesting ;  twenty  hours  after  the  operation  the 
child  could,  with  the  right  eye,  see  the  movements  of  a  hand,  and  in 
two  days  count  fingers  up  to  2  feet,  the  pupil  acting  more  freely.  The 
paracentesis  having  proved  ineffectual  in  the  left  eye,  which  was  still 
absolutely  blind,  iridectomy  was  also  performed  on  this  eye  on  the 
second  day.  This  was  also  successful.  The  ophthalmoscopic  symptoms 
were  equally  fiivourable,  for  on  the  third  day  after  the  second  operation 
the  retinal  arteries  were  found  to  be  normal,  as  also  the  veins,  excepting 
a  slight  irregularity  in  their  fulness.  In  three  months,  the  sight  was 
perfectly  normal  in  each  eye.  Rothmund  mentions  two  similar  cases 
of  ischfemia  of  the  retina,  in  which  paracentesis  proved  effectual,  having, 
however,  to  be  repeated  in  the  second  case. 

11.— EMBOLISM  OF  THE  CENTRAL  ARTERY  OF  THE 
RETINA  (Plate  IV,  Fig.  8). 

The  first  case  of  embolism  of  the  central  artery  of  the  retina  lead- 
ing to  sudden  and  complete  blindness  was  diagnosed  by  Von  Graefe.* 

The  patient  generally  complains  that  the  loss  of  sight  upon  the 
affected  eye  has  taken  place  very  suddenly,  and  is  so  great,  that  he  can 
hardly  distinguish  between  light  and  dark.  On  ophthalmoscopic 
examination,  we  notice  very  marked  and  characteristic  appearances. 
The  optic  disc  is  very  blanched  but  transparent,  the  vessels  upon  it 
being  greatly  attenuated.  The  retinal  arteries  are  extremely  thin, 
resembling  small  narrow  threads,  and  are  perhaps,  to  a  greater  or  less 
extent,  bloodless  and  changed  hei'e  and  there,  for  the  whole  or  a  certain 
part  of  theii'  course,  into  white  bands.  Sometimes  small  red  plugs  or 
coagula  may  be  noticed  in  the  vessels.  The  retinal  veins  are  also 
thinner,  irregularly  filled,  and  showing  in  some  of  the  branches  a  com- 
plete emptiness  for  a  part  of  their  course,  alternating  with  a  column  of 
blood  or  plugs  of  coagula.  In  Von  Graefe's  case  a  very  peculiar  con- 
dition was  observed  in  a  vein,  viz.,  a  very  irregular  movement  of  the 
column  of  blood,  which  moved  with  a  sudden  start  towards  the  optic 
nerve,  and  then  again  became  stationary ;  the  alternatingly  full  and 
empty  portions  of  the  vessels  remaining  as  before,  excepting  that 
their  situation  was  changed.  The  next  change  is  observed  in  the 
region  of  the  yellow  spot,  which  some  days  after  the  outset  of  the 
affection  becomes  opaque  and  covered  by  a  faint  bluish-grey  or  bluish- 

*  "Archiv.  f.  Oplitli.,"  v,  1,  136. 


3G4  DISEASES   OP   THE  RETINA. 

green  film,  hiding  the  subjacent  choroid,  and  gradually  shading  off  at 
the  periphery  into  the  normal  retina.  This  opacity  is  due  to  a  serous 
infiltration  of  the  retina  at  this  point,  and  varies  considerably  in  extent, 
reaching  or  even  exceeding  somewhat  the  size  of  the  optic  disc.  It  is 
generally  ovoid  in  shape,  with  its  longest  diameter  horizontal.  It  often 
shows  a  somewhat  mottled  appearance,  being  studded  with  small,  grey 
granules.  In  the  centre  of  the  film,  at  the  foramen  centrale,  is  noticed 
a  marked,  bright  cherry-red  spot,  which  is  not  an  extravasation  of  blood, 
as  is  often  erroneously  supposed,  but  is  due,  as  Liebreich  has  pointed 
out,  to  the  fact  that  at  this  point  the  retina  is  transparent,  permitting 
the  choroid  to  shine  through,  which  assumes  a  redder  tinge  on  account 
of  the  contrast' with  the  surrounding  greyish- blue  opacity.  The  vessels 
running  towards  the  yellow  spot  are  often  hypereemic,  so  that  their 
finer  branchlets  can  be  distinctly  traced,  and  they  often  also  show  well- 
marked  blood  coagula. 

The  following  case  which  came  under  my  care  at  King's  College 
Hospital  illustrates  well  the  appearances  presented  by  embolism  of  the 
central  artery  of  the  retina  : — 

W.  P.,  set.  42,  married,  has  always  been  in  good  health.  About  the 
beginning  of  April,  1867,  he  had  a  severe  cold,  which  kept  him  in  bed. 
On  the  second  morning  he  noticed  that  the  right  eye  was  somewhat  in- 
flamed, and  smarted,  and  on  trying  his  sight  he  found  that  it  was  much 
affected.  No  more  reliable  history  could  be  obtained.  On  May  16th 
he  first  came  under  my  care.  The  right  eye  looks  healthy,  the  pupil 
somewhat  dilated  and  sluggish,  refracting  media  clear.  He  is,  how- 
ever, totally  blind,  being  hardly  able  to  distinguish  between  light  and 
dark.  The  ophthalmoscope  shows  that  it  is  a  case  of  embolism  of 
the  central  artery  of  the  retina.  The  optic  disc  is  very  pale,  but 
transparent,  the  vessels,  on  its  expanse,  much  attenuated  and  anaemic, 
so  that  it  is  somewhat  difficult  to  trace  their  exact  relations  to  each 
other.  The  outline  of  the  disc  and  the  retina  in  its  vicinity  are  some- 
what hazy.  This  film-like  opacity  increases  in  density  and  extent 
towards  the  region  of  the  yellow  spot,  where  it  assumes  a  greyish-blue 
tint.  The  vessels  running  from  the  disc  towards  the  yellow  spot  are 
numerous  and  somewhat  hyperaBmic,  so  that  their  terminal  branches 
are  very  observable.  In  some,  the  blood  current  is  distinctly  inter- 
rupted, small  red  portions  of  vessel  alternating  with  bloodless  ones. 
I  could  not,  however,  on  the  closest  examination,  detect  any  jerky 
movement  of  the  blood  in  these  vessels ;  and  as  the  red  portions 
of  the  vessel  did  not  appreciately  alter  their  position  during  several 
weeks,  I  attributed  them  to  blood  coagula  in  the  vessel.  In  the  centre 
of  the  yellow  spot  is  noticed  a  red,  cherry- coloured  irregular  patch, 
which  evidently  depends  upon  the  contrast  in  colour  above  referred  to. 
Another  smaller  red  patch  is  observed  somewhat  above  and  to  its  outer 


EMBOLISM  OF  THE  CENTRAL  ARTERY  OF  THE  RETINA.   365 

side,  resembling  it  in  appearance,  but  being  due  to  an  effusion  of  blood. 
Tlie  whole  aspect  of  this  region,  otherwise  resembles  very  closely  the 
appearance  presented  in  the  figure  illustrating  embolism  of  the  centi-al 
artery  of  the  retina  (Plate  iv,  fig.  8).  The  appearance  of  the  retinal 
vessels  is  also  very  characteristic  of  this  aflFection.  Thus,  from  the 
lower  side  of  the  disc  a  small  artery  emerges,  which  is  perfectly  white 
in  the  disc  and  for  some  portion  of  its  course  over  the  retina  (about 
twice  the  diameter  of  the  disc),  where  it  becomes  again  filled  with 
blood.  It  looks,  indeed,  like  a  small  white  band.  The  accompanying 
vein  is  filled  for  a  short  distance  from  the  disc,  but  at  its  first  division 
there  is  a  well-marked  plug,  and  on  the  peripheral  side  of  this,  it  is 
bloodless  for  a  considerable  portion  of  its  course.  Some  of  the  other 
vessels  in  the  vicinity  of  the  disc  show  marked  irregularities  in  their 
fulness,  being,  at  certain  points,  hardly  apparent  or  resembling  small 
white  threads,  and  at  others  well  filled.  These  irregularities  extended 
even  to  some  of  the  peripheral  branches.  The  left  eye  was  quite  normal. 
The  heart  was  examined  by  Dr.  DuflBn,  and  found  healthy.  Although 
the  patient's  health  is  good,  he  appears  suffering  from  some  cerebral 
affection,  as  he  is  very  forgetful,  inconsequent,  and  somewhat 
wandering. 

The  case  was  kept  under  constant  observation,  and  examined  with 
the  ophthalmoscope  at  intervals  of  a  few  days.  Although  the  state 
of  some  of  the  blood-vessels  changed  somewhat,  no  marked  alteration 
in  the  condition  of  things  took  place  until  the  beginning  of  June,  when 
the  disc  became  more  vascular,  but  its  outline  more  indistinct,  the 
retina  at  its  margin,  more  especially  upwards,  looking  oedematous. 
The  vitreous  humour  became  clouded,  showing  diffuse  and  floating 
opacities.  At  the  lower  portion  of  the  fundus,  small  circumscribed 
specks  of  disseminated  choroiditis  were  observed.  In  about  a  fortnight 
two  large  extravasations  of  blood  appeared,  one  at  the  periphery  of  the 
fundus,  the  other  running  from  the  disc  to  the  upper  part  of  the  yellow 
spot.  They  were  evidently  situated  in  the  retina,  just  beneath  the  internal 
elastic  lamina,  as  they  covered  the  retinal  vessels,  and  were  uniform 
and  smooth,  without  any  striated  appearance.  At  the  commencement 
of  July  he  was  sent  to  Walton  Convalescent  Hospital.  In  the  begm- 
ning  of  October  his  eye  presented  the  following  appearance,  which  it  has 
retained  more  or  less  up  to  the  present  time.  The  vitreous  is  quite  clear, 
the  retina  is  undergoing  transparent  atrophy,  the  vessels  are  extremely 
small,  and  the  retina  is  so  thin  that  the  epithelium  of  the  choroid  can 
be  abnormally  well  seen.  The  inner  half  of  the  disc  is  covered  by  a 
thick  network  of  blood-vessels  (collateral  circulation),  which  are  so 
closely  arranged  that  they  present  the  appearance  of  an  extravasation 
of  blood,  but  on  pressing  upon  the  eye,  they  can  be  emptied,  and  be 
observed  to  re-fill  when  the  pressure  is  relaxed.     The  extravasation 


oiji)  DISEASES   OP   THE  RETINA. 

running  from  the  disc  to  the  yellow  spot  has  disappeared,  but  that  at 
the  upper  part  of  the  fundus,  though  much  smaller,  is  yet  very  appa- 
rent. 

12.— HYPERESTHESIA  OF  THE  RETINA. 

Before  the  discovery  of  the  ophthalmoscope,  this  affection  was 
generally  mistaken  for  inflammation  of  the  retina,  and  we  still  meet 
with  this  error  in  some  books  treating  of  diseases  of  the  eye.  Such  a 
mistake  is  a  grave  one,  as  it  has  led  to  a  most  injudicious  and  improper 
treatment  of  cases  of  hypersesthesia  retinae,  viz.,  by  antiphlogistics, 
depletion,  salivation,  etc.,  thus  increasing  the  severity  and  the  duration 
of  the  symptoms. 

HypertEsthesia  of  the  retina  generally  occurs  in  young  persons, 
especially  in  females  of  a  very  excitable,  nervous,  and  hysterical  tem- 
perament, and  in  delicate,  feeble  health.  It  is  sometimes  due  to  an 
accident,  shock,  or  a  blow  on  the  eye,  etc.,  to  exposure  to  very  bright 
light,  such  as  a  flash  of  lightning,  or  to  prolonged  use  of  the  eyes  by 
strong  artificial  light.  It  may  also  occur  without  any  apparent  cause, 
except  some  derangement  in  the  general  health,  more  especially  of  the 
uterine  functions. 

On  examining  the  eye,  we  find  that  there  is  intense  photophobia, 
together  with  lachrymation,  accompanied  perhaps  by  a  spasmodic 
twitching  of  the  eyelids,  or  even  a  severe  spasm  of  the  orbicularis 
muscle.  There  is  often  great  ciliary  neuralgia,  the  pain  extending 
to  the  face  and  the  corresponding  side  of  the  head.  The  retina  is 
extremely  irritable,  and  the  patient  is  greatly  troubled  by  photopsies, 
such  as  bright,  dazzling  stars,  coloured  rings,  etc.,  before  the  eyes,  these 
photopsies  being  either  spontaneous,  or  very  easily  producible  by  the 
slightest  pressure  upon  the  eyeball.  Moreover  the  retina  retains 
impressions  for  an  abnormally  long  period,  so  that  if  any  object  is 
regarded,  its  image  is  retained  for  a  very  appreciable  space  of  time. 
The  eye  itself  will  be  found  quite  normal,  the  refracting  media  clear, 
the  fundus  perfectly  healthy.  The  sight  is  but  very  slightly,  if  at  aU 
impaired,  and  is  always  greatly  improved  when  the  intensity  of  the 
light  is  diminished  by  the  use  of  blue  glasses,  with  which  the  patient 
will  be  able  to  read  the  smallest  print.  But  whilst  the  central  vision 
is  perfect,  the  peripheral  portion  of  the  retina  is  ana3sthetic,  so  that  the 
field  of  vision,  as  is  pointed  out  by  Von  Graefe,  is  markedly  concen- 
trically contracted.  This  fact  might  easily  mislead  a  superficial 
observer  to  mistake  it  for  a  case  of  commencing  amaurosis.  The 
phosphenes*  are,  however,  very  marked  in  the  portion  of  the  retina 
which  is  ana3sthetic,  and  are  very  readily  produced  by  slight  pressure 
upon  the  eyeball. 

*  The  luminous  rings  which  appear  when  the  eyeball  is  firmly  pressed. 


TUMOURS  OF   THE   RETINA.  367 

The  photophobia  is  ofteu  most  severe,  the  patient  being  quite  unable 
to  face  the  light,  or  it  conies  on  dii^ectly  he  attempts  to  nse  his  eyes  in 
reading,  etc.  It  is  always  greatly  relieved  by  the  use  of  dark  blue 
glasses.  Mooren*  mentions  an  extraordinary  case  of  hypera-sthesia,  in 
which  the  sensibility  of  the  retina  was  so  greatly  increased,  that  the 
patient  coiild  read  large  print  in  the  dark,  in  which  a  normal  eye  could 
not  distinguish  a  letter.  It  was  indeed  a  true  case  of  nyctalopia.  All 
these  symptoms  had  become  developed  in  a  very  short  time.  The 
treatment  must  consist  chiefly  in  improving  the  general  health, 
encouraging  the  patient,  and  diminishing  the  excitability  of  the  retina. 
If  the  photophobia  is  severe,  it  may  be  necessary  to  confine  the  patient 
in  complete  dai-kness  for  six  or  eight  days,  and  then  gradually  to 
accustom  him  to  an  increasing  amount  of  light  (Von  Graefe).  In  the 
open  air  he  shoTild  wear  blue  glasses.  Internally,  tonics  should  be 
administered,  more  especially  preparations  of  zinc  or  steel,  according 
to  the  special  indications  of  individual  cases.  Zinc  (either  the  vale- 
rianate or  lactate)  should  be  given  in  increasing  doses,  commencing 
with  ^  to  1  grain  twice  a  day,  and  gradually  increasing  this  to  4  or 
even  5  grains.  Subsequently,  steel  and  quinine  will  be  found  very  use- 
ful. Great  care  must  be  taken  not  to  weaken  the  patient,  especially  by 
depletion.  Although  the  artificial  leech  may  be  occasionally  employed 
with  benefit,  it  must  be  used  with  extreme  care,  otherwise  it  is  apt  to 
increase  the  severity  of  the  symptoms,  and  retard  the  cure.  I  prefer 
dry  cupping,  either  at  the  temple  or  the  back  of  the  neck.  If  the 
patient's  spirits  are  much  depressed,  everything  must  be  done  to  cheer 
him  up  and  encourage  him  in  believing  in  a  speedy  cure. 

13.— TUMOURS  OF  THE  RETINA. 

According  to  Yirchowf  only  two  kinds  of  tumour  occur  in  the 
retina,  viz..  Glioma  and  Glio-sarcoiyia .  The  iutra-ocular  tumour  gener- 
ally known  as  medullary  cancer,  encephaloid  tumour,  or  fungus 
haematodes,  is  in  reality,  as  Virchow  has  shown,  developed  from  the 
retina.  As  it  originates  in  the  interstitial  connective  tissue  (neuroglia) 
of  the  retina,  and  in  this,  as  well  as  in  its  minute  structure,  closely 
resembles  cerebral  glioma,  he  has  termed  it  Glioma  retinoi,  a  name 
which  has  been  already  extensively  adopted  by  Biitish  and  Foreign 
pathologists. 

The  symptoms  presented  by  the  disease  are  generally  very  marked 
and  characteristic.  In  the  earlier  stages,  the  external  appearance  of 
the  eye  is  quite  healthy  and  normal,  there  being,  as  a  rule,  no  pain  or 

*  "  Ophthalmiati-ische  Beobachtungen,"  p.  271. 
t  "  Die  krankliaftcn  Geschwiilste,"  ii,  159. 


3l)b  DISEASES   OF   THE   RETINA. 

symptoms  of  inflammation.  But  the  sight  is  lost.  The  pupil  is  more 
or  less  widely  dilated,  and,  shining  from  the  bottom  of  the  eye,  is 
noticed  a  bright,  glistening,  yellowish- white  reflection,  which  is  often 
already  noticeable  at  some  little  distance.  On  account  of  this  yellow 
luminous  reflex,  this  condition  was  formerly  called  "  amaurotic  cat's- 
eye."  With  the  ophthalmoscope,  the  details  of  the  growth  can  be 
beautifully  seen.  At  the  outset,  the  disease  is  limited  to  one  portion  of 
the  retina,  which  becomes  opaque,  thickened,  and  somewhat  mottled 
in  appearance.  The  morbid  growth  gradually  increases  in  extent  and 
prominence,  until  it  protrudes  in  the  form  of  a  yellowish- white  nodu- 
lated mass  into  the  vitreous  humour.  According  to  Virchow,  the 
increase  in  the  size  of  the  tumour  is  partly  due  to  the  growth  of  the 
original  mass,  and  partly  to  the  formation  of  new  foci  of  disease  in  its 
vicinity  ;  and  hence,  on  becoming  larger,  the  growth  assumes  a  lobu- 
lated  appearance,  certain  portions  of  the  retina  being  thicker  than 
others.  On  the  expanse  of  the  tumour,  we  can  generally  observe  with 
the  ophthalmoscope  numerous  blood-vessels,  which  anastomose  very 
freely  with  each  other,  and  between  these  vessels  are  often  noticed  small 
efiusions  of  blood.  Indeed,  these  tumours  are  very  vascular,  and  this 
fact,  as  Hirschberg*  points  out,  is  not  only  valuable  in  a  diagnostic 
point  of  view,  but  tends  to  explain  the  rapidly  developed  glaucomatous 
symptoms  and  the  temporary  atrophy  of  the  eyeball,  which  are  often 
noticed  in  eyes  afiected  with  glioma. 

The  above  are  the  sjonptoms  generally  presented  by  the  disease 
when  the  surgeon  first  sees  it,  for  as  it  occurs  in  the  vast  majority  of 
cases  in  children,  little  heed  is  paid  to  the  condition  of  the  sight,  and  the 
aff'ection  is  unnoticed  until  the  attention  of  the  parents  is  arrested  by 
the  bright  yellow  reflex  coming  from  the  bottom  of  the  eye,  and  only 
then  is  medical  aid  sought.  Hence  we  but  seldom  enjoy  the  oppor- 
tunity of  seeing  the  earliest  development  of  the  disease,  and  of  fol- 
lowing its  gradual  progress.  In  the  very  earliest  stage,  there  are 
noticed,  according  to  Von  Graefe,t  numerous  small  white  patches,  of 
varying  size,  which  lie  partly  behind  the  retinal  vessels,  and  partly  per- 
vade the  retina  as  far  as  its  inner  surface,  and  then  give  rise,  already 
at  a  very  early  stage,  to  a  marked  elevation.  They  may  be  distin- 
guished from  inflammatory  infiltrations  of  the  retina  by  their  cii^cular, 
sharply  defined  outline,  the  periphery  of  such  figures  not  being  broken 
up  into  punctated  or  striated  opacities,  as  occurs  in  the  former  case. 
Moreover,  they  are  of  a  decidedly  white  tint,  and  not  of  the  creamy 

*  "A.  f.  O.,"  xiv,  2,  50.  Both  Dr.  Hirscliberg's  and  Yon  Graofe's  ai'ticles  upon 
Intra-ocular  Tumours  in  this  vol.  of  the  Archiv.  are  of  the  greatest  interest  and 
importanpe,  as  tlicy  afford  information  and  explanations  upon  many  points  which 
were  hitherto  still  in  doubt. 

t  lb.,  p.  129. 


TUMOURS  OF   THE   RETINA.  369 

yellow  hue  met  with  in  .  inflammatory  infiltrations.  These  small 
patches  soon  coalesce,  and  increase  in  size  and  thickness,  but  spread 
at  first  only  along  the  surface.  But  as  the  disease  advances,  the 
posterior  sui-face  of  the  retina  bulges  forward  (Hii-schberg),*  the  little 
individual  nodules  which  are  thus  formed,  coalesce  and  give  rise  at 
a  circumscribed  spot  to  a  lobulated  cauliflower  growth  of  the  external 
sui'face  of  the  retina  (glioma  retinte  circumscriptum  tuberosum).  At 
this  period,  there  is  already  noticed  a  considerable  dissemination 
of  secondary  foci.  The  retina  is  generally  already  partially  detached 
at  a  very  early  stage,  and  the  tension  of  the  eye  mostly  somewhat 
increased.  The  detachment  is  often  peculiarly  defined,  perhaps  forming 
aji  acute  angle,  at  whose  apex  a  white  patch  maybe  noticed  (Graefe).t 
The  peculiar  reflex  and  the  details  of  the  tumour  are  rendered  still  more 
marked  and  conspicuous  on  the  retina  becoming  detached.  When  the 
disease  is  more  advanced,  and  the  whole  retina  is  implicated  in  it 
and  thickened,  the  detachment  is  generally  complete  and  funnel-shaped, 
the  apex  being  situated  at  the  optic  nerve,  and  the  base  at  the  ora 
serrata.  As  a  rule,  the  morbid  growth  can  be  very  readily  detached 
from  the  choroid,  but  in  some  cases  the  retina  is  firmly  glued  to  the 
latter  (Virchow),J  the  tumoiu"  gradually  filling  the  eyeball  and  causing 
the  vitreous  humour  to  shrink  and  become  absorbed  to  a  corresponding 
degree.  The  retina  in  such  cases  becomes  folded  inwards,  so  that  the 
different  folds  are  super-imposed  upon  each  other. 

When  the  growth  enlarges  still  more,  the  lens  and  iris  become 
pushed  forward  towards  the  cornea,  the  lens  often  becoming  opaque 
and  partially  or  even  completely  absorbed.  The  intra-ocular  tension, 
which  has  generally  been  already  for  some  length  of  time  augmented, 
becomes  now  very  markedly  increased,  and  this  may  be  accompanied  by 
more  or  less  acute  inflammatory  symptoms  and  severe  pain.  The  state 
of  the  eye-tension  is  of  consequence  with  regard  to  the  differential 
diagnosis  between  an  intra-ocular  tumour  and  a  simple  detachment  of 
the  retina,  for  in  the  latter  case  it  is  as  a  rule  always  diminished.  As 
glioma  occurs  in  the  vast  majority  of  cases  in  young  children,  in  whom 
glaucoma  is  hardly  ever  met  with  as  a  primary  affection,  an  increase  in 
the  intra-ocular  tension  (other  causes  for  this  being  absent)  should  at 
once  arouse  our  suspicions  (Graefe).§ 

When  the  tumour  has  filled  the  cavity  of  the  eyeball,  the  latter 
generally  soon  gives  way  at  some  point.  The  perforation  takes  place 
at  the  cornea  or  near  its  margin,  or  at  the  anterior  portion  of  the 
sclerotic,  and  but  seldom  at  its  posterior  part.  Perforation  at  the 
latter  situation,  and  the  extension  of  the  growth  into  the  orbit  must 
be  suspected  if  the  movements  of  the  eyeball  are  markedly  curtailed, 

*  "  A.  f.  O.,"  xiv,  2,  p.  88.  t  Ibid.,  p.  129. 

Z  Loc.  cit.,  p.  162.  §  "  A.  f.  O.,"  xir,  2,  130. 

2   h 


370  DISEASES  OF   THE  RETINA. 

and  tlie  eye  protruded.  When  tlie  tumour  lias  once  burst  throiigh  the 
coats  of  the  eyeball  its  growth  is  very  rapid.  It  sprouts  forth  between 
the  eyelids,  which  are  greatly  swollen  and  often  much  everted,  and 
acquires,  from  its  exposure  to  the  atmosphere  and  external  irritants,  a 
dusky-red,  fleshy,  and  very  vascular  appearance,  and  hence  the  name 
"fungus  hgematodes."  From  it  there  exudes  a  sanious  fluid,  which 
becomes  crusted  on  its  surface,  and  if  any  excoriation  of  the  latter 
occurs,  the  tumour  bleeds  very  freely. 

Sometimes,  however,  the  disease  does  not  run  so  regular  a  course, 
for  after  the  tumour  has  attained  a  certain  size  within  the  eye,  symp- 
toms of  irido- choroiditis  supervene,  the  pupil  becomes  blocked  up  with 
lymph,  the  eye-tension  falls  below  the  normal  standard,  and  the 
disease  for  a  time  assumes  the  character  of  an  irido-choroiditis,  passing 
on  to  temporary  atrophy  of  the  eyeball.  The  latter  is  generally  due 
to  suppurative  choroiditis,  but  may,  in  rare  instances,  be  also  caused 
by  suppuration  of  the  cornea  (Von  Graefe).  Together  with  this 
atrophied  condition  of  the  eyeball,  there  are  often  very  intense,  spon- 
taneous paroxysms  of  pain,  the  eye  itself  being  but  slightly,  if  at 
all  sensitive  to  the  touch.  Whereas,  in  the  atrophy  dependent  upon 
irido- cyclitis  the  reverse  obtains.  But  the  most  intense  and  sudden 
pain  occurs  if  intra-ocular  hfemorrhage  takes  place.  At  a  subsequent 
period,  the  symptoms  of  an  intra-ocular  tumour  again  manifest  them- 
selves in  the  partially  atrophied  eyeball,  the  tension  increases,  the 
tumour  augments  in  size,  the  cornea  or  sclerotic  gives  way,  and  a 
rapidly  increasing  morbid  growth  sprouts  forth. 

Virchow  considers  that  glioma  commences  in  the  external  layers 
of  the  retina,  more  especially  the  connective  tissue  elements  of  the 
granular  layers.  Schweigger*  thought  it  probable  that  it  originated 
in  the  internal  granular  layer,  and  Hii'schbergf  has  succeeded  in 
proving  the  truth  of  this  supposition,  having  found  in  one  case  that 
the  disease  commenced  in  a  proliferation  of  the  cells  in  the  inner 
granular  layer  of  the  retina.  At  a  more  advanced  stage  of  the  disease 
the  retinal  tissues  often  disappear  almost  entirely,  so  that  it  is  then 
quite  impossible  to  trace  its  origin.  J  The  membrana  limitans  interna 
and  the  innermost  portion  of  the  trabecular  connective  tissue  fibres 
(Stiitzfasern),  seem  to  resist  the  longest,  and  may,  according  to 
Virchow,  be  often  traced  within  the  tumour,  and  seen  to  divide  it  into 
segments. 

The  principal  masses  of  tumour  are  composed  of  aggregations  of 
nuclei  and  cells.     The  latter  are  round  or  oval,  small  m  size,  and  occa- 

*  "  A.  f.  O.,"  vi,  2,  326.  t  lb.,  xiv,  2,  40. 

J  For  further  information  upon  the  anatomical  characters  of  these  tumours, 
I  would  also  refer  the  reader  to  Mr.  Hiilkc's  valuable  papers  on  "Intra-ocular 
Cancer,"  "  li.  L.  O.  11.  Rep.,"  iii,  iv,  and  v. 


TUMOURS   OF   THE   RETINA.  371 

sionally  have  small  prolongations.  They  are  sometimes  arranged  in 
rows,  and  contain  one  or  more  nuclei.  The  free  nuclei  are  small  and 
round,  and,  according  to  Virchow,  correspond  exactly  to  the  little 
light-refracting  nuclei  of  the  granular  layer.  The  inter-cellular  sub- 
stance is  so  scanty  that  it  can  be  hardly  distinguished,  but  on  adding 
chromic  acid  it  becomes  finely  granular.  In  the  soft  variety  of  the 
tumour  the  cells  are  larger  than  in  the  hard,  and  in  the  latter  the 
cellular  tissue  is  fibrillated.  The  tumour  may  subsequently  undergo 
fatty  and  chalky  degeneration.  Sometimes  the  cells  augment  in  size 
or  assume  a  spindle  shape,  and  the  nuclei  increase  in  number,  and  then 
the  morbid  growth  must  be  considered  to  be  of  a  sarcomatous  nature. 
Indeed,  Virchow  has  shown  that  the  tumour  sometimes  assumes  a 
mixed  character,  one  part  resembling  glioma  in  structure,  another  sar- 
coma, so  that  it  may  be  termed  "  glio-sarcoma,"  and  he  thinks  this  to 
be  far  more  dangerous  in  character  than  simple  glioma.* 

Iwauofft  regards  the  small  outgrowths  from  the  membrana  limitans 
interna  observed  in  cases  of  retinitis,  and  which  sprout  into  the  vitreous 
humoui",  in  the  light  of  small  gliomata.  They  do  not,  however,  appear 
to  have  anything  in  common  with  glioma.  Virchow  thinks  that  a  sharp 
lino  of  demarcation  cannot  be  drawn  between  glioma  and  inflammatory 
neoplasms  of  the  retina,  as  the  former  may  in  its  course  be  accompanied 
by  inflammatory  symptoms.  He  considers  "  that  the  name  gUoma  is 
apposite,  as  the  neo- plastic  formation,  even  if  of  an  inflammatory  nature, 
assumes  a  more  permanent  character  and  tumour- like  form,  it  being, 
however,  of  course,  always  understood  that  its  structure  must  be  com- 
posed of  homologous  elements.  A  suppurative  retinitis  can  never  give 
rise  to  glioma."]: 

Von  Graefe,  however,  does  not  believe  that  glioma  is  due  to  an 
inflammatory  hyperplasia,  and  thinks  that  observations  which  have  been 
advanced  in  support  of  such  a  view,  have  depended  either  upon  the  fact 
that  the  sequelae  of  intra-ocular  inflammations,  e.g.,  plastic  inflammations 
of  the  vitreous  humour,  or  subretinal  deposits,  have  been  mistaken  for 
gliomas ;  or  that  the  first  period  of  the  tumour  has  been  completely 
overlooked,  and  the  consecutive  inflammatory  complications  were  sup- 
posed to  form  the  origin  of  the  disease.  Moreover,  as  he  points  out, 
clinical  observation  shows  a  marked  difierence  between  the  first  period 
of  glioma  and  an  inflammatory  hyperplasia. 

The  question  whether  glioma  is  to  be  regarded  as  a  malignant  disease 
is  still  considered  doubtful  by  some  observers.  Von  Graefe,§  however, 
now  speaks  in  the  most  decided  manner  as  to  its  malignancy,  and 
thinks  that  this  increases  with  the  length  of  its  existence  and  the 
increase  of  its  development.     Glioma  diSers,  however,  from  sarcomatous 

*  "  Krankhafte  Gescliwiilste,"  ii,  167.  t  "  A.  f.  O.,"  xi,  1,  143. 

X  Loc.  cit.,  159.  §  Loc.  cit.,  xiv,  2,  110. 

2  B  2 


372  DISEASES  OF   THE   RETINA. 

tumours  of  the  choroid,  etc.,  in  this,  that  it  does  not  appear  second- 
arily to  affect  distant  organs,  being  only  prone  to  local  infection.*  Thus 
Rindfleishf  found  in  a  case  of  glioma  that  there  was  a  small  nodule  of 
tumour  between  the  choroid  and  sclerotic,  and  that  similar  products 
existed  in  the  optic  nerve.  Hulke|  mentions  a  case  in  which  the  retinal 
glioma  in  each  eye  extended  above  the  optic  nerves  within  the  skull, 
and  in  which  he  distinctly  observed  the  growth  of  the  glioma  in  the 
connective  tissue  separating  the  bundles  of  nerve  fibres  in  the  nerve- 
trunk,  in  front  of  the  optic  commissure.  The  propagation  of  the 
disease  frora  the  retina  occurs  in  two  directions — (1)  towards  the  choroid; 
(2)  to  the  optic  nerve ;  and  the  disease  of  the  latter  is,  according  to 
Hirschberg,  more  frequent  than  has  been  generally  supposed.  Out  of 
the  eight  cases  which  he  reports, §  the  optic  nerve  was  implicated  in 
six,  and  in  most  to  a  very  considerable  extent.  In  this  tendency  to  exten- 
sion of  the  disease  to  the  optic  nerve  and  thence  to  the  brain,  is  to  be 
sought  the  extreme  danger  of  retinal  glioma,  for  a  secondary  tumour  of 
the  brain  may  be  formed,  or  encephalitis  ensue.  Hence  the  necessity  of 
excising  the  eye  at  the  earliest  opportunity,  and  dividing  the  optic 
nerve  as  far  back  as  possible.  The  first  retro-ocular  extension  of  the 
disease  is  very  difficult  to  diagnose,  but  Yon  Graefe||  has  found  that 
when  degeneration  of  the  optic  nerve  has  ensued,  the  eyeball  becomes 
slightly  more  prominent,  and  its  lateral  movements  somewhat  curtailed. 
There  is  also  more  resistance  felt,  if  the  eye  is  pressed  back  into  the 
orbit,  and  the  little  fuiTow  between  the  eyelids  and  wall  of  the  orbit  is 
obliterated.  When  the  orbital  adipose  tissue  is  once  implicated,  the  pro- 
gress of  the  disease  is  very  rapid. 

The  causes  of  glioma  are  often  quite  obscure ;  but  in  some  cases  it 
is  clearly  due  to  a  traumatic  origin.  It  occurs  far  more  frequently  in 
children  than  in  adults,  and  generally  between  the  ages  of  two  and  ten. 
It  may,  according  to  Travers,  be  sometimes  congenital,  he  having  extir- 
pated such  an  eye  in  a  child  of  eight  months  old.  Sometimes  both  eyes 
are  affected  with  the  disease,  and  in  such  cases  Graefe  thinks  that  we 
must  not  consider  the  affection  as  having  been  propagated  from  one  eye  to 
the  other  by  way  of  the  chiasma,  for  in  the  cases  of  Saunders  and  Hayes, 
reported  by  Wardrop,  the  optic  nerve  of  the  secondarily  afiected  eye 
was  found  to  be  quite  normal.  N'or  does  the  idea  of  a  dyscrasia  hold 
good,  on  account  of  the  immunity  of  other  organs  from  metastatic  or 
secondary  gliomata.  Yon  Graefe  rather  seeks  the  explanation  in  the 
peculiar  symmetry  which  exists   between  the  two  eyes,  the  influence 

*  At  the  Heidelberg  Oplithalmological  Congress  of  this  year,  Knapp,  however, 
narrated  a  case  of  glioma  of  the  retina  in  which  tlicre  were  found,  after  death, 
secondary  gliomata  in  the  liver,  lung,  and  the  diploe  of  the  skidl. 

+  "  Kl.  Moiiatsbl.,"  1863,  3il.  X  "  R.  L.  O.  II.  Rep.,"  v,  1V2. 

§  "  A.  f.  O.,"  xiv,  2,  56.  II  "  A.  f.  O.,"  xvi,  2, 137. 


TUMOURS   OF   THE   RETINA.  373 

of  which  is  so  often  and  very  markedly  illustrated  in  inflammatory 
diseases  of  the  eye.  In  some  instances,  glioma  appears  to  be  here- 
ditary, and  occurs  in  several  members  of  the  same  family.  Thus 
Lerche  mentions  four  children  being  affected  with  it  out  of  a  family  of 
seven  ;  Sichel  saw  it  in  foui'  children  of  the  same  mother.  The  children 
affected  with  glioma  are  often  of  a  peculiarly  fair  and  beautiful  com- 
plexion, although  perhaps  somewhat  delicate  in  constitution. 

The  prognosis  of  the  disease  is  always  extremely  grave,  as  the 
affection  is  very  apt  to  recur,  and  we  have  no  guarantee  that  the  optic 
nerve  is  not  already  implicated,  even  although  the  intra-ocular  tumour 
may  still  be  very  small.  For  this  reason,  the  immediate  removal  of 
the  eye  should  be  very  strongly  ui'ged  as  soon  as  the  diagnosis  of 
glioma  is  established,  for  this  is  the  only  chance  of  saving  the 
patient's  life.  The  opinion  that  the  disease  may  become  spontane- 
ously arrested,  or  may  retrograde,  is  according  to  Von  Graefe  quite 
erroneous.  For  he*  has  found  that  the  affection  progresses  steadily 
and  surely,  indeed  with  greater  steadiness  than  sarcoma  of  the  cho- 
roid, and  that,  reckoning  from  the  earliest  appearance  of  the  disease, 
when  the  tumour  still  only  occupies  a  small  portion  of  the  eye,  from 
one  to  three  years  elapse  before  its  extra-ocular  development  becomes 
manifest.  In  those  cases  in  which  this  occurs  at  very  early  age,  e.g., 
at  the  termination  of  the  first  year  of  the  child's  life,  he  considers  it 
probable  that  the  glioma  was  congenital. 

It  has  been  urged  by  some  surgeons,  that  the  extirpation  of  the  eye  is 
useless,  as  the  disease  is  sure  quickly  to  recur  and  end  fatally.  But  cases 
are  on  record  in  which  several  years  have  elapsed  after  the  operation, 
without  a  retui'n  of  the  disease. t  The  rule  is,  therefore,  to  remove  the 
eye  at  the  earhest  possible  period,  so  that  there  may  be  the  chance  of 
the  optic  nerve  being  still  unaffected. 

The  chief  danger  is,  that  the  disease  should  extend  to  the  brain,  or 
that  the  tumour,  increasing  more  and  more  in  size,  should  perforate 
the  eyeball,  and  from  the  severe  pain,  the  great  enlargement  of  the 
tumour,  the  occurrence  of  haemorrhage,  etc.,  undermine  the  patient's 
health.  Cerebral  complications  should  be  suspected,  if  the  patient 
becomes  drowsy,  languid,  and  stupid,  lying  about  and  sleeping  a  great 
deal,  if  there  is  great  and  constant  headache,  or  if  symptoms  of 
paralysis  manifest  themselves.  But  even  when  the  tumour  has  bui'st 
through  the  coats  of  the  eyeball,  and  is  fungating  extensively,  its 
removal  is  advisable,  more  especially  if  there  is  much  pain  and 
haemorrhage.  It  must,  moreover,  be  remembered  that  it  is  the  only 
chance  of  prolonging  life,  and  of  alleviating  the  dreadful  sufferings  of 
the  patient.     In  excising  the  eye,  the  optic  nerve  should  be  divided 

*  "  A.  f.  O.,"  xiv,  2,  135. 

t  Vide  "  R.  L.  O.  H.  Eep.,"  iv,  87  j  also  V.  Q-raefe's  Article,  loc.  cit. 


374  DISEASES   OF   THE   RETINA. 

very  far  back,  in  order,  if  possible,  to  remove  all  the  disease.  Von 
Graefe  is  in  the  habit,  in  such  cases,  of  passing  a  neurotome  (after 
he  has  divided  the  conjunctiva)  along  the  outer  wall  of  the  orbit  to  the 
bottom  of  the  latter,  then  pulling  the  eye  as  far  forward  as  possible, 
and  dividing  the  optic  nerve  quite  close  to  the  optic  foramen ;  he  then 
proceeds  with  the  excision  in  the  usual  manner.  If  the  disease  has 
extended  to  the  tissue  of  the  orbit,  it  will  be  advisable  to  apply  the 
chloride  of  zinc  paste  after  the  removal  of  the  eyeball,  so  as  to  destroy, 
if  possible,  all  the  morbid  tissue. 

14.— ATROPHY  OF  THE  RETINA. 

Atrophy  of  the  retina  is  met  with  as  the  final  stage  of  many  of  the 
intra-ociilar  inflammations,  of  glaucoma,  and  cerebral  amaurosis.  It 
may  be  partial  and  confined  to  certain  portions  or  elements  of  the 
retina,  or  complete,  the  whole  retina  becoming  greatly  attenuated  and 
changed  into  a  thin,  transparent,  fibrillar  connective  tissue,  which  is 
so  delicate  that  the  details  of  the  choroid  can  be  seen  with  unusual 
distinctness,  and  the  faint,  normal  reflex  of  the  retina  is  entirely 
absent.  The  retinal  vessels  become  excessively  attenuated,  and  at  last 
changed  into  thin  streaks  or  lines,  or  disappear  more  or  less  completely. 
The  optic  nerve  at  the  same  time  shows  all  the  symptoms  of  advanced 
degeneration  (perhaps  glaucomatous  excavation)  and  atrophy.  In  the 
retinal  atrophy  which  ensues  upon  inflammation,  the  retina  is  generally 
for  a  time  more  or  less  opaque,  and  studded  perhaps  here  and  there 
with  patches  of  exudation,  but  subsequently  it  becomes  more  and  more 
thinned  and  transparent.  Deposits  of  pigment  and  cholesterine  are 
sometimes  noticed  in  the  atrophied  tissue. 

15.— CYSTS  IN  THE  RETINA. 

These  may  occur  in  varying  number,  and  difier  in  size  from  a  small 
pea  to  a  hazel  nut.  On  a  section  of  the  globe,  they  appear  to  the 
naked  eye  as  small  transparent  vesicles,  studded  over  the  outer  portion 
of  the  retina.  They  are  probably  produced  by  the  development  of 
colloid  material  in  the  external  granular  layer,  and  by  a  proliferation 
of  the  radiating  trabecular  fibres  (Iwanofi").*  The  latter  form  the  outer 
and  lateral  walls  of  the  cyst,  the  internal  wall  being  formed  by  the 
internal  layers  of  the  retina.  Mr.  Vernon  has  met  with  cysts  in  the 
retina  in  four  instances,  which  will  be  fully  reported  in  "  R.  L.  0.  H. 
Rep.,"  vi,  3. 

*  "  Kl.  M.,"  1864,  p.  417. 


Chapter  IX. 
DISEASES   OF   THE   OPTIC   NERVE. 


1.— INFLAMIVIATION     OF     THE     OPTIC     NERVE    (OPTIC 
NEURITIS,  NEURO-RETINITIS)  Plate  VI,  Figs.  13  and  14. 

IxFLAMMATiON  of  the  optic  nerve  is  distinguished  by  the  following 
ophthalmoscopic  symptoms.  At  the  outset,  there  exists  a  certain  degree 
of  hypersemia  and  oedema  of  the  optic  nerve  entrance  and  of  the  retina 
in  its  vicinity,  so  that  the  disc  appears  abnormally  red  and  somewhat 
opaque  and  swollen,  its  outline  being  hazy  and  indistinct.  In  some  cases 
the  neuritis  is  partial,  the  serous  infiltration  and  swelling  being  at  first 
chiefly  or  entii'ely  confined  to  one  portion  of  the  disc.  But  the  in- 
flammatory symptoms  soon  become  more  marked.  The  optic  disc 
becomes  enlarged,  swollen,  and  prominent,  and  its  outline  irregular  and 
indistinct  (from  the  exudation  of  lymph  covering  the  choroidal  ring), 
so  that  it  passes  over  into  the  retina  without  any  sharp  line  of  demarca- 
tion. Moreover,  the  smooth,  transparent,  delicate  pink  appearance  of 
the  disc  is  lost,  and  it  assumes  an  opaque  reddish-grey  tint ;  the  effu- 
sion of  lymph  into  the  optic  nerve  causing  it  to  appear  striated  and 
"  woolly."  On  account  of  the  great  swelling  and  prominence  of  the 
disc,  it  can  be  seen  at  some  little  distance  in  the  erect  image ;  the  re- 
fraction having  in  fact  become  hypermetropic.  The  inflammation 
generally  extends  ruore  or  less  on  to  the  retina  in  the  vicinity  of  the 
disc,  rendering  the  former  hazy  and  indistinct.  The  appearance  of  the 
retinal  vessels  is  also  markedly  changed.  The  veins  are  much  dilated, 
dark,  and  often  very  tortuous,  dipping  here  and  there  into  the  infiltra- 
tion, so  as  to  be  more  or  less  covered  and  hidden  by  it,  and  interrupted 
in  their  course.  The  arteries  may,  on  the  other  hand,  be  so  much 
diminished  in  calibre  as  to  be  hardly  distinguishable.  On  account  of 
the  development  of  numerous  small  vessels  on  the  disc,  the  latter  is 
very  red  and  vascular,  its  edge  looking  perhaps  as  if  it  were  covered 
by  a  reddish  fringe.  On  and  around  the  disc,  are  scattered  numerous 
striated  blood  extravasations,  of  varying  size  and  shape.  On  using  a 
high  magnifying  power,  we  are  often  able  to  make  out  that  the  apparent 
hoemorrhaglc  effusions  in  reality  consist  of  minute,  closely  packed,  newly 


376  DISEASES   OF   THE   OPTIC   NERVE. 

developed  blood-vessels.  The  inflammatory  swelling  and  exudation 
may,  however,  be  so  considerable  that  the  vessels  are  completely  hidden 
on  the  disc,  and  can  only  be  followed  up  to  its  margin,  and  only  here 
and  there  can  the  outline  of  a  vessel  be  faintly  traced  on  its  expanse. 
Although  cases  of  retinitis,  more  especially  the  parenchymatous  and 
nephi'itic,  are  generally  accompanied  by  a  certain  degree  of  inflamma- 
tion of  the  optic  nerve,  I  shall  here  confine  myself  to  the  description 
of  optic  neuritis  as  an  idiopathic  disease,  and  not  as  a  part  symptom  of 
inflammation  of  the  retina. 

We  may  disting-uish  two  principal  forms  of  optic  neuritis,  viz.,  1. 
The  ^'^  engorged  papilla,''*  (Stauung's  papille  ofY.  Graefe),  in  which 
the  inflammation  commences  in  the  papilla  (optic  disc)  and  extends 
upwards  along  the  trunk  of  the  nerve,  but  generally  stopping  short  at 
the  lamina  cribrosa.  Hence  it  might  very  well  be  termed  "  ascending" 
neuritis. 

2.  The  "  descending  neuritis,"  in  which  the  inflammation  commences 
extra-ocularly  and  extends  downwards  to  the  optic  disc. 

The  engorged  papilla  is  almost  always  due  to  an  impediment  in  the 
circulation  vsdthin  the  nerve,  which  may  be  caused  by  an  intra-orbital 
tumour  pressing  upon  the  nerve,  or  by  an  increase  in  the  intra-cranial 
pressure  and  consequent  retardation  and  impediment  of  the  circulation 
in  the  ophthalmic  vein.  This  mechanical  obstruction  to  the  circulation 
in  the  central  vessels  of  the  retina,  is  soon  followed  by  serous  infiltra- 
tion of  the  optic  nerve,  and  subsequently  by  inflammatory  proliferation 
of  its  connective  tissue  elements.  Hence,  there  is  a  considerable 
swelling  of  the  nerve,  and  as  the  firm  scleral  ring  cannot  yield,  but 
closely  embraces  it,  the  nerve  is  here  more  or  less  strangulated,  wliich 
impedes  the  circulation  still  more.  The  irritation  produced  by  this 
compression  is  soon  followed  by  inflammation. 

Von  Graefef  was  the  first  to  recognise  the  connection  between 
optic  neuritis  and  affections  of  the  brain,  as  well  as  certain  morbid  con- 
ditions of  the  orbit.  According  to  him,  the  engorged  papilla  is  chiefly 
distinguished  by  great,  but  perhaps  partial,  swelling  and  prominence  of 
the  disc,  numerous  and  considerable  hajmorrhages  on  and  around  the 
papilla,  and  great  dilatation,  darkness,  and  tortuosity  of  the  veins ;  the 
arteries  being  on  the  contrary  very  small,  attenuated,  and  often  almost 
bloodless.  The  inflammatory  infiltration  of  the  retina  is  confined  to 
the  close  vicinity  of  the  nerve  entrance.  In  the  descending  neuritis  the 
tissue  of  the  nerve  is  more  diS"usely  clouded,  but  the  swelKng  and 
redness  of  the  disc  are  much  less,  and  its  tint  is  of  a  faint  grey.     The 

*  The  "  ischsemia  of  the  disc "  of  Dr.  AUbutt,  whose  interesting  Lectures  on 
Optic  Neuritis,  "  Med.  Times  and  Gazette,"  1868,  I  would  strongly  recommend  to 
the  attention  of  the  reader. 

t  "  A.  f.  O.,"  vii,  2,  58. 


INFLAMMATION   OF   THE   OPTIC   NERVE.  377 

opacity  of  the  retina  is  more  diffuse  and  extensive,  and  reaches  deeper 
into  its  structure.  The  retinal  arteries  are  considerably  diminished  in 
calibre,  but  the  veins  are  less  dilated  and  tortuous  than  in  the  engorged 
papilla.  On  account  of  the  more  extensive  implication  of  the  retina, 
as  well  as  the  appearance  of  white  patches  on  it,  the  disease  sometimes 
assumes  a  certain  similarity  to  nephritic  retinitis,  and  might  even  be 
mistaken  for  it  by  a  superficial  careful  observer.  The  chief  points  in 
the  differential  diagnosis  of  these  two  diseases  have  been  already  men- 
tioned in  the  article  upon  the  "  Retinitis  Albuminurica"  (page  338), 
On  account  of  its  involving  so  considerable  a  portion  of  the  retina,  this 
form  might  be  called  nenro-retinitis. 

It  must  be  stated,  however,  that  the  distinctive  characters  of  these 
two  forms  of  neuritis  are  not  often  so  strongly  marked,  and  also  that 
the  one  may  pass  over  into  the  other,  and  thus  give  rise  to  a  mixed 
group  of  ophthalmoscopic  appearances.  Sometimes  in  the  descending 
neuritis,  the  opacity,  swelling,  and  redness  are  chiefly  confined  to  the 
periphery  of  the  disc,  the  central  portion  being  relatively  but  little 
involved. 

In  some  cases  of  optic  neuritis  in  children,  Mr.  Hutchinson  has  met 
with  a  peculiar  appearance  of  the  retina  in  the  region  of  the  yellow 
spot,  viz.,  a  group  of  highly  refractive  globules,  resembling  at  the  first 
glance  a  cluster  of  spider's  eggs ;  these  groups  are  almost  symmetrical 
and  very  definite.* 

When  the  inflammatory  symptoms  subside,  the  morbid  products 
become  gradually  absorbed,  the  swelling  and  prominence  of  the 
papilla  diminish,  and  it  gradually  becomes  flat;  at  the  same  time  assum- 
ing a  paler  tint,  the  neighbouring  retina  remaining  perhaps  a  little 
clouded.  The  retinal  veins  diminish  in  size  and  tortuosity,  the  blood 
extravasations  become  absorbed,  the  opacity  of  the  retina  disappears, 
and  the  disc  may  gradually  regain  a  more  normal  appearance,  and 
vision  may  be  restored.  As  the  swelling  and  infiltration  of  the  nerve 
are  far  more  considerable  in  the  engorged  papilla  than  in  the  de- 
scending neuritis,  the  absorption  is  also  less  rapid  than  in  the  latter.  In 
severe  cases  recovery  is,  however,  the  exception  not  the  rule,  for  the 
nerve  generally  becomes  atropliied.  Even  in  those  cases  in  which 
vision  is  restored,  the  disc  remains  somewhat  opaque  and  of  a  palish 
creamy  tint.  We  are,  however,  generally  able  for  a  long  time  to  dis- 
tinguish the  atrophy  ensuing  upon  optic  neuritis,  from  that  which  is  met 
with  in  cerebral  Or  cerebro-spiual  amaurosis,  and  which  is  termed  simple 
or  progressive  atrophy.  In  the  atrophy  consecutive  upon  optic  neuritis, 
the  outline  of  the  disc  remains  somewhat  hazy  and  indistinct,  and  does 
not  show  the  clearly  cut,  sharply  defined  contour  so  characteristic  of  the 
other  form.  The  disc  may  also  remain  somewhat  swollen,  and  its 
*  "  Ophth.  Hosp.  Rep.,"  V,  4,  308. 


378  DISEASES  OF   THE  OPTIC   NERVE. 

whiteness  lacks  transparency  and  lastre,  being  dull  and  of  an  opaque 
and  somewhat  creamy  tint.  The  retinal  veins,  moreover,  retain  for  a 
long  time  a  certain  degree  of  dilatation  and  tortuosity,  but  as  time 
passes  on  these  differences  gradually  fade  away,  and  finally  the  disc 
assumes  the  appearance  of  that  met  with  in  simple  progressive  atrophy. 
When  the  infiltrations  into  the  optic  nerve  and  retina  become  absorbed, 
we  often  notice  a  slight  thinning  and  atrophy  of  the  choroid  at  these 
points. 

The  disease  generally  afiects  both  eyes  (especially  where  it  is  due 
to  cerebral  causes),  either  simultaneously  or  at  a  very  short  interval, 
being,  according  to  Bouchut,  most  marked  in  the  eye  corresponding 
to  the  hemisphere  which  is  most  severely  involved.  If  the  cause  is 
intra- orbital,  it  is,  of  course,  quite  difierent.  I  have,  however,  met  with 
"an  instance  iri  which  the  disease  (the  cause  of  which  could  not  even  be 
surmised)  remained  entirely  confined  to  one  eye. 

The  sight  is  often  greatly  impaired.  Sometimes,  the  loss  of  vision 
is  very  sudden,  the  patient  becoming  perhaps  so  blind  within  a  few 
hours  or  days,  as  to  be  quite  unable  to  distinguish  between  light  and 
dark.  But  the  impairment  of  vision  does  not  necessarily  correspond  to 
the  striking  morbid  alterations  presented  by  the  disease ;  indeed,  the 
sight  may  even  be  perfectly  normal  in  cases  of  marked  optic  neuritis. 

I  have  at  the  present  time  a  case  of  monocular  neuritis  under  my 
care,  in  which  the  acuity  of  vision  has  remained  perfectly  normal  through- 
out, and  a  short  time  ago  I  saw  two  cases  of  optic  neuritis  with 
Dr.  Hughlings  Jackson,  in  each  of  which  the  patient  could  read  No.  1 
of  Jager ;  indeed.  Dr.  Jackson  assures  me  that  such  cases  are  by  no 
means  of  unfrequent  occurrence,  but  are  not  often  observed  by  the 
oculist,  simply  because  the  latter  is  only  consulted  when  the  sight  is 
beo-innino"  to  fail.  Whereas,  the  physician  is  called  in  on  account  of 
some  other  symptom,  he  suspects  cerebral  disease,  examines  the  eyes 
with  the  ophthalmoscope,  discovers  optic  neuritis,  and  yet  finds  that 
the  sio-ht  is  unimpaired.  Mauthner*  narrates  an  interesting  case,  in 
which  a  patient  affected  with  optic  neuritis  retained  a  normal  acuteness 
of  vision  up  to  the  time  of  his  death  (which  was  sudden).  The  post- 
mortem examination  revealed  the  existence  of  interstitial  optic  neuritis, 
but  the  retina  was  healthy  quite  up  to  the  optic  nerve. 

The  field  of  vision  is  generally  also  more  or  less  afiected,  and  this  is  a 
point  of  much  prognostic  importance,  for  according  to  Von  Graefe,t  we 
almost  always  find  that  in  those  cases  of  optic  neuritis  in  which  the 
field  of  vision  is  contracted,  at  least  a  partial  atrophy  of  the  optic  nerve 
and  retina  ensues.  The  pupil  is,  as  a  rule,  dilated  and  sluggish,  or  even 
perhaps  almost  immovable.    But  if  the  sight  is  good,  it  may  be  hardly, 

*  "  Leln-bnch  dcr  OpMlialmoscopie,"  p.  293. 
t  "  Kl.  Monatsbl.,"  p.  9,  18fi3. 


INFLAMJIATION   OF   THE   OPTIC   NERVE.  379 

if  at  all,  affected.  The  patient  is  often  much  troubled  with  subjective 
appearances  of  light  (photopsies  and  chromopsies)  which,  from  their 
fantastic  shapes  and  constant  presence,  may  prove,  a  source  of  great 
distress  and  anxiety.  If  the  neuritis  is  due  to  a  cerebral  cause,  it  is 
generally  accompanied  by  more  or  less  marked  symptoms  of  brain 
disease,  such  as  loss  of  memory,  giddiness,  vomiting,  impairment  of  the 
sense  of  smell,  taste,  or  hearing,  epileptoid  fits,  paralytic  affections, 
severe  headache,  etc.  The  cephalalgia  is  often  very  great  and  protracted, 
the  patient  being,  perhaps,  unable  to  locahse  it  exactly,  as  it  extends 
over  the  whole  head.  Von  Graefe  calls  attention  to  the  fact  that  in 
cases  of  cerebral  tumoui',  the  position  of  the  latter  may  sometimes 
be  ascertained  by  the  acute  pain  produced  by  sharply  tapping  with  the 
finger  the  corresponding  portion  of  the  cranium,  which  also  temporarily 
increases  the  severity  of  the  general  headache. 

Causes. — The  engorged  papilla  may  be  caused  by  morbid  processes 
within  the  orbit,  which  give  rise  to  great  protrusion  of  the  eye,  or  pres- 
sure upon  the  optic  nerve,  and  consequently  impediment  of  the  circu- 
lation. Amongst  such  causes,  must  be  especially  instanced  tumom's, 
and  inflammation  of  the  periosteum  or  the  cellular  tissue  of  the  orbit. 
In  such  cases,  we  often  enjoy  an  opportunity  of  watching  how  the 
symptoms  of  optic  neuritis  disappear,  and  the  sight  becomes  restored, 
when  the  tumoui'  has  been  removed,  or  the  inflammation  has  subsided 
and  the  eye  returned  to  its  normal  position. 

This  form  of  optic  nearitis  is,  moreover,  very  frequently  produced 
by  certain  cerebral  affections  which  exert  a  direct  pressure  upon  the 
cavernous  sinus,  and  thus  impede  the  venous  cu'culation,  or  effect  this 
by  an  increase  in  the  pressure  of  the  intra-cranial  circulation  (e.g.,  in 
hydrocephalus).  Amongst  these  causes,  cerebral  tumours  must  be 
especially  mentioned,  being  situated,  perhaps,  at  the  base  of  the  brain, 
or  in  the  hemispheres.  This  impediment  of  the  circulation  in  the 
ophthalmic  vein,  gives  rise  to  mechanical  congestion  of  the  papilla, 
which,  as  has  been  already  mentioned,  is  soon  followed  by  serous  infil- 
tration, and  subsequently  by  inflammatory  proliferation  of  the  connective 
tissue  elements  of  the  optic  nerve.  But,  as  was  originally  pointed  out 
by  Von  G-raefe,  the  obstruction  in  the  cavernous  sinus  alone  would  not 
suffice  for  this,  but  the  effect  of  the  firm,  unyielding  sclerotic  ring  in 
increasing  any  tendency  to  stasis  in  the  circulation  must  also  be  taken 
into  account.  Cases  of  engorged  papilla,  in  which  cerebral  tumours  were 
found  after  death,  have  been  recorded  by  Von  Graefe*  and  others. 
But  although  tliis  form  of  optic  neuritis  will  lead  us  to  suspect  the 
presence  of  a  cerebral  tumour,  it  is  by  no  means  always  diagnostic  of 
it,  as  such  tumours  may  in  some  cases  produce  simple  ati'ophy  of  the 
optic  nerve  by  direct  pressui'e  upon  the  latter.  Or  they  may  set  up 
*  "Kl.  Monatsbl.,"  p.  9,  1863  ;  also  "A.  f.  O.,"  vii,  2,  58. 


380  DISEASES  OF   THE  OPTIC   NERVE. 

inflammation  of  the  meninges,  wliicli,  extending  to  the  optic  nerve,  gives 
rise  to  descending  neuritis.  The  latter  disease  is,  therefore,  sometimes 
met  with  in  cases  of  meningitis  or  arachnitis,  in  which  the  inflammation 
extends  to  the  optic  nerve,  and  trav6lS  dowil  to  the  papilla  and  retina. 
We  may,  however,  have  mixed  forms  of  neuritis,  in  which  the  phe- 
nomena presented  by  the  disease  are  partly  due  to  inflammation  of  the 
trunk  of  the  nerve,  and  partly  to  obstruction  in  the  circulation. 

In  one  case  of  descending  neuritis  narrated  by  Von  Graefe,*  the  cir- 
cumscribed basilar  meningitis  was  found  to  be  caused  by  a  peculiar 
entozoon,  situated  partly  in  the  right  hemisphere  and  partly  at  the  base 
of  the  cranium. 

Indeed,  according  to  Dr.  Hughlings  Jackson,t  who  has  made  so 
many  interesting  and  valuable  researches  upon  the  affections  of  the  eye 
met  with  in  cerebral  diseases,  optic  neuritis  may  be  produced  by 
"  coarse  "  disease  of  almost  any  part  of  the  cerebrum,  or  cerebellum. 
This  being  so,  I  cannot  do  better  than  give  the  following  summary 
of  his  experience  and  views,  which  appeared  in  the  Hospital  Reports  of 
the  "  British  Medical  Journal"  (March  28,  1868). 

"We  now  report  remarks  on  an  acute  condition  of  the  optic  nerves, 
which  is  followed  by  another  kind  of  atrophy.  It  is  to  be  kept  in  mind 
that  the  following  remarks  apply  to  cases  of  optic  neuritis  ('descending 
neuritis ')  seen  in  physicians'  practice,  and  contain  an  accurate  although 
a  very  brief  statement  of  the  chief  conclusions  at  which  Dr.  Hughlings 
Jackson  has  arrived. — Optic  neuritis  from  intracranial  disease  is  always 
double,  even  when  the  disease  giving  rise  to  it  is  quite  limited  to  a 
single  cerebral  hemisphere. — Not  unfrequently  one  eye  suffers  more  than 
the  other,  but,  even  when  one  cerebral  hemisphere  is  alone  diseased, 
there  does  not  seem  to  be  any  constant  relation  betwixt  the  side  of  the 
brain  affected  and  the  eye  more  affected. — Although,  in  physicians' 
practice,  the  local  disease  causing  optic  neuritis  is  most  often  of  the 
cerebral  hemisphere,  it  may  be  in  any  part  of  either  the  cerebral  or  cere- 
bellar hemispheres,  or  at  the  base  of  the  skull. — Dr.  Hughlings  Jackson 
has  not  yet  found  optic  neuritis,  nor  indeed  optic  atrophy  of 'any  kind, 
with  disease  limited  to  the  optic  thalamus,  to  the  pons,  or  to  the  medulla 
oblongata. — The  intracranial  disease  is  almost  always  coarse. — The  intra- 
cranial disease  may  be  of  many  kinds,  probably  of  any  coarse  kind. 
Thus  Dr.  Hughlings  Jackson  has  found  optic  neui'itis  with  tumour,  with 
abscess,  with  blood-clot,  with  syphilitic  "  deposit,"  and  with  hydatid 
cyst,  and  all  these  of  the  cerebral  hemisphere. — He  has  not  found,  with 
one  exception,  any  but  the  most  trifling  unusual  intra-ocular  appear- 
ances  in   the   chorea  of  children ;   a  disease  which  he  supposes  (see 

*  "  Kl.  M.,"  1864,  p.  367. 

+  Vide  Dr.  IlugUlings  Jackson's  contributions  upon  these  subjects  in  the  "  R.  L. 
O.  H.  Reports,"  "  The  London  Hospital  Reports,"  "  Mod.  Times,"  etc. 


^ 


INFLAMMATION   OF   THE   OPTIC   NERVE.  381 

'London  Hospital  Reports,' vol.  i.,   1864;  '  Lancet,' Nov.  2Gtli,  1864; 
'  Med.  Times   and   Gazette,'   Jan.   28tli,  1865)  to  depend,  at  least  fre- 
quently on  plugging  of  small  branches  of  the  middle  cerebral  artery. 
Chorea  in  children  does  not  at  all  events  depend  on  coarse  disease  of 
the   brain.     From   a   superficial   point  of  view  it  is,  Dr.  Hughlings 
Jackson  thinks,  somewhat  striking  that  marked  pathological  changes 
in  the  optic  discs  are  not  unfrequently  found  with  unilateral  spasm,  and 
with  unilateral  palsy,  and  scarcely  ever  with  tinilateral  irregular  move- 
mentsl    (jiioreitorm  movements  are  sometimes  observed  during  recovery 
from  the  '  epileptic  hemiplegia '  which  occasionally  occm\s  with  optic 
neuritis.     However,   the  real  association  is  not  of  optic  neuritis  with 
one-sided  spasm  or  palsy,  but  with  intracranial  coarse   disease,  which 
coarse  disease,  when  it  is  of  one  cerebral  hemisphere,  may  produce  both 
optic  neuritis  and  the  condition  (corpus  striatum  neuritis  ?)  on  which 
the  one-sided  spasm,   or  palsy,  or  both   depend.     We  should  not,  he 
thinks — making  a  mistake  analogous  to  that  the  old  astronomers  made 
— consider  amaurosis,  from  optic  neuritis,  or  the  atrophy  which  follows 
it,  to  be  the  centre  point  of  a  case  around  which  all  the  other  symptoms 
'  revolve ;'  but  rather  try  to   find  the    central  disease — in  physicians' 
practice  often  coarse  disease  of  one  cerebral  hemisphere — to  which  each 
of  the  symptoms  (^Headache,  convulsions,  amaurosis  from  optic  neuritis), 
is  equally  subordinate.     He  thinks  it  is  not  warrantable,  even  when  we 
find  a  lump  of  syphihtic  disease  in  the  cerebral  hemisphere  post  mortem, 
to  say  that  optic  neuritis  is  '  caused  by  syphilis,'  since  just  the  same 
ophthalmoscopic  appearances  may  occur  with  other  sorts  of  'foreign 
bodies'  in  the  veiy  same  part  of  the  brain.     How  it  happens  that  a 
foreign  body  in  the  brain  sometimes  '  excites  '  changes  about  itself,  and 
sometimes  does  not,  is   the    subject  of  speculations  of  very  different 
kinds  into  which  we  do  not  now  enter. — Optic  neuritis  does  not  depend 
on  loss  of  function  of  the  part  which  the  coarse  disease  destroys,  as  does 
loss   of    power   of  intellectual   expression    (aphasia). — Optic   neuritis 
requires  time  for  its  production.     Thus,  although  it  occui-s  with  blood- 
clot,  it  never,  in  Dr.  Hughlings  Jackson's  experience  at  least,  occurs  with 
I'ecent  blood- clot. — When  coarse  disease  of  one  cerebral  hemisphere  gives 
rise   to   headache,  vomi  tlilg ,  "SunTateral    spasm,   amaui'osis  from  optic 
neuritis ;  'or,  "let  us  say,  to  the  larger  uproar  called  '  cerebral  fever,' 
involving  all  or  most  of  these,  the  probability  is  that  there  is  but  one 
idea  throughout,  viz.,  a  '  foreign  body,'  and  changes  diffused  from  it  in 
different  directions,  on  which  diffused  changes  the  symptoms  directly 
depend. — The  most  important  clinical  fact  about  optic  neuritis  is,  that 
it  may  exist  for  a  varying  time — a  few  days,   a  few  weeks,  or  a  few 
months — without  any  apparent  defect  of  sight.     It  must  he  looked  for  in 
eveiT  case  of  cerebral  disease,  at  all  events  in  every  case  of  cerebral 
fever. — It  is  necessary  to  look  for  it  in    cases  of  loss  of  speech  from 


382  DISEASES  OF  THE   OPTIC   NERVE. 

disease  of  the  liemispliere.  As  implied  in  the  foregoing,  it  is  only  likely 
to  occur  in  cases  where  the  speech  defect  depends  on  coarse  disease,  let 
us  say  on  a  large  clot,  and  then  only  some  time  after  the  seizure.  A 
blood-clot  causes  loss  of  speech  as  a  destroyer  of  an  elaborate  structure, 
and  subsequently  optic  neuritis  in  its  character  as  a  foreign  body. 
However,  optic  neuritis  is  rarely  associated  with  blood- clot." 

But  we  sometimes  meet  with  cases  of  optic  neuritis,  [in  which  it 
is  quite  impossible  to  detect  any  cause  or  any  impairment  of  the 
health,  except  perhaps  some  derangement  of  the  uterine  functions,  e.g., 
insufficiency  of  the  catamenia.  I  have  seen  several  instances  of  this 
kind  in  young  and  delicate  females,  who  otherwise  enjoyed  perfect 
health.  Such  cases  recover  completely,  if  they  are  seen  at  the  outset 
of  the  disease,  and  are  actively  and  efficiently  treated.  Mr.  Hulke,  in 
an  interesting  paper  on  optic  neuritis,*  narrates  such  cases,  and  also 
others,  in  which  it  occurred  in  connection  with  diphtheria,  rheumatic 
fever,  etc. 

To  prove  that  the  distinction  between  the  engorged  papilla  and  the 
descending  neuritis  is  not  a  theoretical  or  arbitrary  one,  we  need  only 
pay  attention  to  the  differences  in  the  anatoraical  changes  met  with  in 
these  two  forms.  In  the  engorged  papilla,  the  inflammatory  changes 
are  generally  chiefly  confined  to  the  intra-ocular  end  of  the  optic  nerve, 
and  do  not,  as  a  rule,  extend  backwards  beyond  the  lamina  cribrosa, 
although  the  intimate  structure  of  the  latter  is  often  greatly  changed, 
and  its  characteristic  features  rendered  indistinct. f  MauthnerJ  has 
seen  some  preparations  of  Iwanoff 's,  in  which  the  proliferation  of  the 
connective  tissue,  instead  of  stopping  short  at  the  lamina  cribrosa,  had 
extended  somewhat  along  the  trunk  of  the  nerve,  and  had  thus  given 
rise  to  ascending  neuritis. 

In  descending  netu-itis,  Virchow§  found  that  besides  hypertrophy  of 
the  vessels  and  increase  in  the  width  of  the  nerve  fibres,  the  whole 
trunk  of  the  nerve  had  undergone  inflammatory  changes.  The  neu- 
rilemma was  thickened,  and  showed  cystoid  detachments.  Besides 
this  peri-neuritis,  the  elements  of  the  interstitial  connective  tissue 
had  undergone  proliferation,  producing  degeneration  and  destruction  of 
the  nerve  tubules. || 

The  prognosis  must  m  all  cases  be  extremely  doubtful  and  guarded, 
and  in  the  great  majority  ujifavourable,  for  as  a  rule  optic  neuritis  ends 
in  more  or  less  complete  atrophy  of  the  nerve  and  loss  of  sight. 
Besides  the  question  of  vision,  it  must  also  be  remembered  that  there 
arises  the  still  more  important  one  of  life,  for  but  too  frequently  optic 

*  "  R.  L.  O.  H.  Ro]).,"  vi,  2.  t  Schweigger,  Yorlcsungen,  p.  136. 

X  "  Lchrbuoh  der  Ophllialmoscopic,"  p.  289.     §  "  A.  f.  O.,"  xii,  2,  117. 
II  Vide  also  Dr.  Leber's  mtcrestiiig  paper  on  Optie  Neuritis,  "A.  f.  O.,"  xiv,  2, 
333. 


INFLAMMATION   OF   THE   OPTIC   NERVE.  383 

neuritis  is  caused  by  most  dangerous  and  incurable  affections  of  the 
brain.  The  most  favourable  cases  are  those  in  wliicli  the  disease  is  due 
to  S(ime  temporary  and  relievable  cause,  such  as  irregularities  in  the 
catamenia,  etc.,  or  a  tumour  or  inflammation  in  the  orbit.  But  even  in 
these,  the  morbid  changes  in  the  optic  nerve  may  have  been  so  great  as 
to  prevent  any  restitution  ad  integrum.,  and  the  end  is,  atrophy  of  the 
nerve  and  blindness.  On  the  whole,  the  cases  in  which  the  progress  of 
the  disease  and  the  loss  of  sight  have  been  very  rapid,  afford  a  more 
favourable  prognosis  than  those  in  which  they  have  been  slow  and 
gradual.  In  the  former  instance,  a  perfect  recovery  may  result,  even 
although  all  quantitative  perception  of  light  has  been  temporarily  lost.* 

With  regard  to  the  treatment,  we  can  only  lay  down  general  rules, 
as  it  must  be  varied  according  to  the  nature  of  the  cause  and  the 
exigencies  and  peculiarities  of  individual  cases.  If  the  disease  is  seen 
at  the  outset,  the  patient  should  be  placed  as  soon  as  possible  under 
the  influence  of  mercury  (inunction).  If  the  patient  is  deHcate,  tonics 
should  be  at  the  same  time  administered.  I  have  several  times  ob- 
served that  this  line  of  treatment  has  exerted  a  markedly  favourable 
influence  upon  the  progress  of  the  disease  and  the  morbid  effusion,  the 
absorption  of  which  it  hastens  and  facilitates.  This  is  especially  the 
case  when  the  disease  occurs  without  any  special  intra- orbital  or  cerebral 
cause,  as  in  females  suffering  from  derangement  of  the  uterine  func- 
tions, or  persons  affected  with  the  suppression  of  some  customary 
discharge,  or  gi-eat  inaction  of  the  skin.  In  some  of  these  cases  I  have 
seen  a  complete  recovery  resulting  from  the  combined  influence  of 
mercury  and  the  local  application  of  the  artificial  leech.  The  action  of 
the  skin  should  be  stimulated  by  diaphoretics,  and,  if  the  patient  will 
submit  to  it,  a  course  of  treatment  by  Zittmann's  decoction,  which 
proves  especially  beneficial  in  syphilitic  cases.  If  the  disease  is  not 
seen  till  a  later  stage,  when  permanent  changes  in  the  nerve  have 
already  occm^red,  I  do  not  think  that  any  benefit  will  be  derived  from 
salivation,  and  should  prefer  the  administration  of  small  doses  of  the 
bichloride  of  mercury,  perhaps  in  combination  with  the  iodide  and 
bromide  of  potassium. 

The  severe  and  often  very  violent  pain  in  the  head  with  which  the 
patients  are  frequently  affected  when  the  disease  depends  upon  a  cerebral 
lesion,  is  generally  relieved  by  a  suppurating  blister,  or,  still  better,  a 
seton  in  the  nape  of  the  neck. 

To  alleviate  the  congestion  of  the  optic  nerve  and  retina,  the  artificial 
leech  should  be  applied  several  times  at  intervals  of  a  few  days,  but 
should  then  be  desisted  from  if  no  benefit  results.  If  the  patient  is 
weak  and  delicate,  dry  cupping  should  be  substituted. 

*  "A.  f.  0.,"xii,  2,  133. 


384  DISEASES  OF   THE   OPTIC   NERVE. 

Under  the  head  of  optic  neuritis,  Von  Graefe*  has  lately  called 
attention  to  cases  in  which  there  was  an  extremely  sudden  loss  of  sight, 
the  patient  becoming,  without  any  clearly  defined  cause,  so  absolutely 
blind  in  the  course  of  a  few  hours  as  to  be  unable  to  distinguish 
between  light  and  darkness.  He  says  : — "  After  constitutional  diseases 
of  different  kinds  (I  have  observed  it  occurring  after  measles,  febrile 
gastric  catarrh,  and  anginge),  but  without  any  marked  disturbance  of 
the  general  health,  the  field  of  vision  becomes  clouded,  with  or  without 
the  presence  of  chromopsies  and  photopsies,  and  within  the  course  of  a 
few  hours  or  days  absolute  blindness  ensues.  Both  eyes  are  generally 
symmetrically  afiected,  and  only  in  a  single  case  have  I  seen  the  disease 
confined  to  one  eye.  This  case,  however,  presented  some  slightly 
irregular  characters.  The  pupil  generally  becoraes  unusually  dilated, 
and  quite  inactive  to  the  stimulus  of  light,  retaining  but  a  slight  degree 
of  mobility  during  the  movements  of  the  eye  or  the  impulse  of  accom- 
modation. There  is,  therefore,  reason  to  assume  the  existence  of  a 
special  state  of  irritation  in  the  fibres  of  the  sympathetic.  With  the 
ophthalmoscope  may  be  observed  undoubted,  though  not  very  con- 
spicuous, changes  in  the  papilla,  which  are,  however,  of  a  markedly 
transitory  character.  Its  tissue  is  veiled  by  a  dehcate,  diffuse  opacity, 
as  is  also  the  neighbouring  retina,  the  level  of  the  disc  is,  however, 
hardly  raised,  or  only  in  a  very  slight  degree,  and  only  for  a  few  days. 
The  arteries  are  narrowed,  but  by  pressing  upon  the  eye  we  can  still 
succeed  in  producing  a  slight  pulsation  (the  surest  sign  of  the  existence 
of  a  continuous  circulation)  ,t  the  veins  are  dilated  and  tortuous,  but 
their  course  is  tolerably  regular  on  account  of  the  but  slight  opacity  of 
the  tissues."  Von  Graefe  narrates  four  cases  of  this  kind.  In  two  a 
complete  recovery  occurred,  even  although  there  had  been  absolute  loss 
of  even  quantitative  perception  of  light  for  some  little  time.  In 
another  case  the  absolute  bhndness  continued,  and  the  disease  passed 
over  into  rapid  atrophy  of  the  nerve.  In  the  foui'th,  there  was  incom- 
plete recovery  with  partial  atrophy. 

Von  Graefe  considers  that  in  all  probability  these  were  cases  of 

*  "Archiv.  f.  O.,"  xii,  2,  135. 

t  If  a  thrombus  iu  tlie  central  artery  of  the  retina  has  produced  ischsemia  of  the 
retina,  the  arteries  of  the  latter  will  also  be  extremely  small,  but  even  a  considerable 
pressure  on  the  eyeball  with  the  finger  will  not  succeed  in  producing  arterial  pulsa- 
tion or  emptying  of  the  arteries.  With  regard  to  this  subject,  You  Graefe  says  at 
another  place :  "If  together,  with  a  free  venous  efflux,  thrombosis  occurs  in  the 
region  of  the  lamina  cribrosa  or  behind  it,  we  must  expect  to  find  the  retinal  arteries 
empty.  But  if  the  venous  efflux  has  been  impeded  by  the  swelling  of  the  tissues, 
either  simultaneously  or  at  an  carher  date,  the  arteries  may  remain  partially  filled, 
but  on  the  other  hand  pressure  upon  the  eyeball  will  not  produce  the  usual  pheno- 
mena, on  account  of  tl«3  stoppage  in  the  iuilux  of  the  blood."  ("Arch.  f.  O.,"  xii, 
2,  134,  note.) 


ATROPHY   OF   THE   OPTIC   NERVE.  385 

retro- ocular  neuritis,  the  swelling  and  diffuse  opacity  being  due  to 
an  interstitial  serous  infiltration  (cBdema).  The  difference  between 
this  form  and  the  descending  neuritis  consists  principally  in  this,  that 
the  more  marked  tissue  alterations  do  not  extend  to  the  papilla,  that 
the  disease  occurs  only  at  certain  points,  and  does  not  involve  con- 
tinuously the  whole  trunk  of  the  nerve.  In  fact,  the  degree  of  inflam- 
mation is  only  very  moderate,  and  the  disease  but  seldom  depends 
upon  grave  intra-cranial  lesions. 

Von  Graefe  thinks,  moreover,  that  certain  cases  of  ischasmia  retinae, 
as  also  perhaps  of  embolism  of  the  central  artei-y  of  the  retina,  may 
have  been  in  reality  cases  of  retro-ocular  neuritis. 

2.— ATROPHY    OF   THE   OPTIC   NERVE    (Plate  VI.,  Figs.  11 

and  12). 

I  shall  here  confine  myself  to  a  description  of  the  various  ophthal- 
moscopic symptoms  presented  by  different  forms  of  atrophy  of  the 
optic  nerve,  and  reserve  the  consideration  of  the  causes,  prognosis,  and 
coui'se  of  this  disease  until  we  come  to  treat  of  the  amblyopic  and 
amaurotic  affections  of  the  eye. 

Some  observers  have  thought  that  the  atrophic  changes  in  the  optic 
nerve  are  usually  ushered  in  by  a  well  marked  hypersemic  condition  of 
the  papilla.  Great  care  is,  however,  required,  not  to  mistake  physio- 
logical peculiarities  in  the  colour  of  the  disc  as  being  of  pathological 
import.  Thus,  as  has  been  already  stated,  the  nasal  side  of  the  disc  is 
often  considerably  redder  than  the  outer  side,  its  edge  being  there- 
fore slightly  indistinct ;  and  yet  this  is  quite  a  physiological  appear- 
ance. In  the  amblyopia  dependent  upon  irregularities  (congestion) 
in  the  cerebral  circulation,  hypertemia  of  the  papilla  is  often  seen, 
as  also  after  prolonged  straining  of  the  accommodation ;  but  I  do  not 
think  that,  as  a  rule,  it  is  met  with  as  a  premonitory  stage  of  the  pri- 
mary, progressive  atrophy  of  the  optic  nerve.  The  more  intimate  ana- 
tomical nature  of  the  simple,  progressive  atrophy  of  the  optic  nerve  is 
still  very  doubtful.  Some  observers  believe  that  there  exists  a  primary 
stage  of  irritation  in  the  interstitial  cellular  tissue,  which  leads  second- 
arily to  the  disappearance  of  the  conductive  nerve  elements.  In 
favour  of  this  \dew  might  be  ui'ged  the  symptoms  which  not  unfre- 
quently  occur  in  the  progress  of  the  disease,  e.g.,  pains  in  the  head, 
unconsciousness,  etc.  But  neither  in  amaurosis  nor  in  tabes  dorsalis 
does  there  appear  to  be  inflammation  of  the  cellular  tissue  of  the  nerves 
in  the  ordinary  sense  of  the  word.* 

The  ophthalmoscopic  symptoms  Avliich  especially  characterise 
atrophy  of  the  optic  nerve  are  a  pale,  white  or  bluish-white  discolouration 

*  Vide  Graefe's  Lectures  on  Amaurosis,  "Kl.  M.,"  1865,  p.  157. 

2  c 


386  DISEASES   OF   THE   OPTIC  NERVE. 

of  the  papilla,  diminution  in  the  calibre  and  number  of  tlie  little  nutri- 
tive blood-vessels  upon  tlie  expanse  of  the  disc,  attenuation  of  the  retinal 
vessels,  more  especially  the  arteries,  and  frequently  a  peculiar  excava- 
tion of  the  optic  nerve. 

In  atrophy  of  the  optic  nerve  (more  especially  the  forms  met  with  in 
cerebral  or  cerebro-spinal  amaurosis)  the  papilla  does  not  present  the 
normal,  greyish-pink  tint,  but  looks  pale  and  white.  Sometimes,  this 
whiteness  is  so  great  as  to  cause  the  disc  to  resemble  a  piece  of  smooth 
white  paper,  but  there  is  frequently  a  bluish- white  or  greenish  reflex, 
yielding  a  peculiar  lustre.  In  the  former  case,  the  plane  of  the  disc  is 
quite  level,  and  the  dead  white  colour  is  chiefly  due  to  the  atrophy  of 
the  nerve  tissue  and  the  hypertrophy  and  thickening  of  the  connective 
tissue  elements  of  the  nerve.  The  bluish- white  reflex  is,  on  the  other 
hand,  due  to  changes  in  the  nerve  tubules  between  the  meshes  of  the 
lamina  cribrosa,  which  render  the  details  of  the  latter  peculiarly  dis- 
tinct. In  such  cases  there  is  always  excavation  of  the  nerve.  Very 
frequently  these  two  conditions  co-exist,  so  that  we  have  a  shallow 
excavation  with  the  details  of  the  lamina  cribrosa  only  partially 
exposed,  the  other  portion  being  covered  by  a  thick  layer  of  connective 
tissue  (Graefe). 

Besides  being  pale  and  discoloured,  the  disc  has  also  lost  its 
transparency  and  peculiar  clearness  of  tint,  so  that  the  retinal  vessels 
cannot  be  distinctly  traced  passing  into  the  substance  of  the  papilla. 
Although  the  outline  of  the  disc  may  be  somewhat  irregular  in  shape, 
it  is  very  clearly  and  sharply  defined,  and  the  choroidal  ring  appears 
unusually  distinct.  The  size  of  the  papilla  may  also  seem  to  be  some- 
what diminished,  but  not  much  importance  should  be  attached  to  this 
symptom,  which  is,  moreover,  often  diie  to  causes  situated  in  the  re- 
fraction of  the  eye.  The  bluish,  or  bluish-green  tint  is  often  met  with 
in  cases  of  spinal  amaurosis,  of  which  indeed  some  authors  consider 
it  almost  pathognomonic* 

The  retinal  vessels  are  generally  diminished  in  size,  and  often  con- 
siderably so.  The  little  blood-vessels  upon  the  disc  are  attenuated  or 
have  disappeared,  and  this  of  course  also  tends  still  more  to  blanch  the 
papilla.  The  retinal  arteries  are  often  so  narrow,  as  to  resemble  minute 
threads,  being  hardly  traceable  upon  the  retina  at  some  little   distance 

*  Mautlmer  calls  attention  to  the  blue  or  bluish-green  discolouration  of  the 
papilla  which  was  first  described  by  Jaeger,  but  does  not  consider  that  it  is 
pathognomonic  of  atrophy  of  the  nerve  except  other  symptoms  {e.g.,  attenuation  of 
the  retinal  vessels)  of  the  latter  affection  are  also  present.  Where  this  is  not  the 
case,  he  still  considers  the  prognosis  hopeful  as  regards  the  sight,  for  not  only  may 
the  degree  of  vision  remain  stationary,  but  even  undergo  wonderful  improvement. 
He  points  out,  moreover,  that  these  changes  in  the  colour  of  the  disc  are  best  seen 
in  the  erect  mode  of  examination  and  by  a  weak  illumination,  as  with  Helmholtz's 
or  Jaeger's  ophthalmoscope.     ("  Lehrbuch  der  Ophtlialmoscopie,"  p.  294.) 


ATROPHY   OF   THE   OPTIC   NERVE.  387 

from  the  disc,  but  their  principal  trunks  can  generally  be  easily  recog- 
nised upon  the  papilla.  The  retinal  veins  are  mostly  also  somewhat 
diminished  in  calibre,  but  to  a  less  extent  than  the  arteries.  We, 
however,  sometimes  meet  with  cases  of  chronic,  complete  amaurosis 
with  well  marked  symptoms  of  nerve  atrophy,  and  yet  the  principal 
retinal  vessels  retain  their  normal  diameter.  The  most  marked  attenua- 
tion of  the  vessels  is  seen  in  cases  of  atrophy  consequent  upon  retinitis 
or  choroido-retinitis. 

^Vliilst  the  above  are  the  symptoms  presented  by  progressive  atrophy 
of  the  optic  nerve,  the  form  of  atrophy  which  is  consecutive  upon  optic 
neuritis  retains  for  a  long  time  special  characteristic  peculiarities,  which 
generally  enable  us  to  distinguish  it  from  the  former  kind,  and  also 
from  that  which  ensues  upon  retinitis  pigmentosa,  etc.  Finally,  how- 
ever, these  distinctive  characteristics  gradually  fade  away,  and  it 
assumes  the  appearance  of  progressive  cerebral  atrophy.  In  the  earlier 
stage,  it  is  chiefly  distinguished  from  the  latter  by  the  fact  that  the 
papilla  remains  slightly  swollen,  having  a  dull  and  opaque,  greyish- 
white,  faintly  clouded  appearance.  Its  outline,  moreover,  is  not 
sharply  defined,  but  uneven  and  indistinct,  passing  over  gradually  and 
almost  insensibly  into  the  faintly  clouded  retina,  so  that  the  disc  ap- 
pears surrounded  by  a  slight  halo.  The  retinal  veins  also  remain  some- 
what dilated,  veiled,  and  tortuous.  Sometimes  we  may  distinctly 
foUow  the  atrophic  changes  in  one  portion  of  the  papilla,  whilst  the 
other  still  retains  the  peculiar  characters  of  neuritis.  These  appearances 
are  well  illustrated  in  Liebreich's  Atlas,  Plate  xi,  figs.  8  and  9. 

I  must  here  call  attention  to  the  fact  that  Mr.  Wordsworth, 
]\Ir,  Hutchinson  and  some  other  observers,  consider  that  a  peculiar  and 
characteristic  form  of  atrophy  of  the  optic  nerve  is  met  with  in  tobacco- 
amaurosis. 

Mr.  Hutchinson  in  a  paper  on  Tobacco- Amaurosis,  read  before  the 
Roy.  Med.  Chu-.  Society,*  says : — "  I'ne  cases  wliick'form  the  subject  of 
this  paper  are  recognised  by  the  loss  of  vascular  supply  to  the  optic- 
nerve  itself.  There  is  not  usually'much  dimmuiion  m  tJie  size  ot  the 
vessels  which  supply  the  retina,  and  often  these  remain  of  good  size 
when  the  nerve  itself  is  as  white  as  paper.  The  first  stage  (one  which 
is  usually  very  transitory,  and  perhaps  often  altogether  omitted)  is  one 
of  congestion,  diu-ing  which  the  disc  looks  too  red.  Then  follows  pallor 
of  the  outer  half  of  the  nerve  disc,  that  part  which  is  nearest  to  the 
yellow  spot.  During  these  stages  the  patient  complains  of  dimness  of 
vision  merely.  Everything  seems  in  a  fog  to  him,  but  he  has  no  pain 
in  the  eyes  nor  any  photophobia  or  photopsiae.  In  a  later  stage  the 
whole  of  the  optic  disc  has  become  pale,  even  to  blue-milk  whiteness  ; 

*  "  Transactious  of  the  Eoy.  Med.  Cliir.  Society,"  1867,  p.  411. 

2  c  2 


388  DISEASES   OF   THE   OPTIC   NERVE. 

and  later  still  there  is  proof,  not  only  of  anaemia  of  the  nerve,  but  of 
advanced  atrophy.  The  stages  generally  occupy  from  four  months  to  a 
year.  In  many  cases  the  patient  becomes  at  length  absolutely  blind, 
but  in  others,  the  disease  having  advanced  to  a  certain  point,  is  arrested. 
There  is  from  first  to  last  no  evidence  of  disease  of  any  structure  in 
the  eyeball,  excepting  the  optic  nerve,  and  even  after  years  of  absolute 
blindness,  the  retina,  choroid,  etc.,  remain  healthy  and  their  blood 
supply  good.  Almost  always  both  eyes  are  affected,  and  progress 
almost  pari  passu.  Sleepiness,  a  little  giddiness,  and  a  little  head- 
ache are  usually  the  only  constitutional  symptoms  vphich  attend  it,  and 
these  disappear  at  a  later  stage  and  the  patient  regains  his  usual  health. 
As  there  is  no  tendency  to  fatal  complications,  opportunities  for  post- 
mortem examination  of  ibhe  brain  are  hardly  ever  obtained." 

In  cases  of  lateral  hemiopia,  we  may  also  in  rare  instances  meet  with 
a  partial  atrophy  of  the  disc  with  excavation,  which  corresponds  to  that 
half  of  the  optic  nerve  which  is  supplied  by  the  fibres  from  the  affected 
optic  nerve.  But  a  long  time  elapses  before  symptoms  of  such  atrophy 
begin  to  show  themselves  ;  indeed,  hemiopia  may  exist  for  a  very  long 
period  without  the  slightest  trace  of  atrophy  being  recognisable. 


3.— EXCAVATION  OF  THE  OPTIC  NERVE. 

There  are  three  forms  of  excavation  or  cupping  of  the  optic  nerve, 
viz.,  1.  The  congenital  j)hysiological  excavation.  2.  The  excavation  from 
atrophy  of  the  optic  nerve.     3.  The  glaucomatous  or  pressure  excavation. 

In  the  congenital  physiological  excavation,  we  find  that  the  cupping  is 
generally  limited  to  the  central  portion  of  the  optic  disc ;  that  it  is 
mostly  very  small  and  shallow,  and  that  it  may  continue  throughout 
life  without  undergoing  any  changes.  In  some  cases,  the  cup  is  not 
situated  in  the  centre  of  the  disc,  but  slightly  towards  the  outer 
(temporal)  side.  Sometimes  the  excavation  is  well  marked  and  easily 
recognisable,  the  central  portion  of  the  optic  disc  presenting  a  peculiar 
white,  glistening  appearance,  of  varying  size  and  form.  This  central 
ghstening  spot  may  be  oval,  cu'cular,  or  longitudinal,  and  its  size  is 
generally  very  inconsiderable  in  comparison  with  that  of  the  optic  disc  ; 
it  is  surrounded  by  a  reddish  zone,  which  may  even  be  almost  of  the 
sam.e  colour  as  the  background  of  the  eye.  The  width  of  this  zone 
varies  with  the  extent  of  the  excavation ;  if  the  latter  be  small,  the 
zone  will  be  very  considerable ;  but  if  it  be  large,  the  zone  will  be 
narrow,  and  limited  to  the  periphery  of  the  disc.  The  edges  of  the  cup 
are  generally  slightly  sloping,  and  never  abrupt  or  steep,  the  excava- 
tion passing  gradually  over  into  the  darker  zone,  without  there  being 
any  sharply- defined  mai'gin.     But  if  the  excavation  is  conical  or  funnel- 


EXCAVATIONS   OF   THE   OPTIC   NERVE.  380 

shaped,  tlie  edges  are  more  abrupt,  and  the  margin  more  defined.  We 
find  that  the  retinal  vessels  also  undergo  peculiar  changes  in  their 
course  from  the  periphery  towards  the  centre  of  the  disc,  for  when  they 
arrive  at  the  margin  of  the  excavation,  instead  of  passing  straight  on, 
they  describe  a  more  or  less  acute  curve  as  they  dip  down  into  it.  This 
curve  may  be  very  slight  and  gradual  if  the  cup  is  shallow,  but  if  it  is 
deep  and  extensive,  the  curve  may  be  abrupt,  giving  rise  to  a  displace- 
ment of  the  vessels.  In  the  expanse  of  the  excavation,  the  vessels 
generally  assume  a  slightly  darker  shade  ;  sometimes  they,  however, 
appear  of  a  lighter,  more  rosy  hue,  and  seem  to  be  enveloped  by  a 
delicate  veil. 

In  some  cases,  as  was  first  pointed  out  by  H.  Miiller,  the  surface  of 
the  same  disc  may  show  a  physiological  dcpi'ession  and  elevation.  The 
outer  portion  of  the  disc  is  shghtly  excavated,  whereas  the  nasal  half  is 
elevated,  and  the  two  halves  of  the  papilla  present  most  marked  and 
striking  differences,  which  might  easily  be  mistaken  for  pathological 
appearances  by  a  careless  observer.  In  such  a  case,  we  find  that  the  cup 
has  no  sharply- defined  border,  and  that  in  its  expanse  the  peculiar  stip- 
pUng  due  to  the  lamina  cribrosa  is  very  observable,  which  is  not  the  case 
in  the  other  half.  The  colour  of  the  excavated  portion  is  pale  and  whitish, 
being  in  strong  contrast  with  the  elevated  part,  which  appears  ab- 
normally red  and  vascular.  The  outline  of  the  disc  also  differs,  for  at 
the  temporal  side  it  is  sharply  defined  and  the  scleral  ring  very  ap- 
parent ;  whereas,  at  the  nasal  side  it  is  indistinct  and  more  or  less 
hidden.  The  retinal  vessels  can  be  seen  to  mount  up  from  the  centre 
of  the  disc  over  the  edge  of  the  elevation,  at  which  point  they  are 
somewhat  bent,  sometimes  to  such  a  degree,  that  their  continuity  may 
be  slightly  lost. 

Ill  the  excavation  from  atroplirj  of  the  optic  nerve,  we  also  meet  with 
well  marked  and  very  characteristic  symptoms.  The  retinal  vessels 
will  be  found  greatly  diminished  in  calibre,  the  arteries  small  and 
thread-like,  perhaps  hardly  apparent ;  the  veins  may  at  first  retain 
their  normal  size,  or  be  even  slightly  dilated,  but  in  the  course  of  the 
disease  they  also  diminish  greatly  in  diameter.  The  colour  of  the 
disc  is  likewise  changed ;  instead  of  the  rosy-yellow  appearance  which 
it  presents  in  the  normal  eye,  it  assumes  a  more  or  less  greyish- white 
or  bluish- white  colour,  which  may  be  limited  to  a  portion  of  the  disc  or 
extend  to  its  whole  expanse,  lending  it  a  peculiar  glistening,  tendinous, 
or  mother-of-pearl  appearance.  The  bluish-grey  colour  of  the  optic  nerve, 
as  has  been  already  stated,  is  often  met  with  in  spinal  amaurosis  ;  being 
by  some  considered  almost  characteristic  of  this  affection.  The  atrophic 
excavation,  although  perhaps  extensive  on  the  surface,  is  generally  very 
shallow,  the  descent  being  gradual  and  sloping,  not  abrupt ;  consequently, 
the  retinal  vessels,  on  arriving  at  the  edge  of  the  cup  from  the  periphery 


390  DISEASES  OF   THE  OPTIC   NERVE. 

of  the  disc,  do  not  show  any  marked  displacement,  but  only  describe  a 
more  or  less  acute  curve.  Sometimes  this  curve  is  so  slight  that  it  is 
hardly  perceptible.  Even  in  those  rare  cases  in  vs^hich  the  excavation 
is  tolerably  deep,  the  descent  is  not  abrupt,  and  for  this  reason  there  is 
no  marked  displacement  of  the  vessels  at  its  edge ;  and  on  moving  the 
convex  lens  of  the  ophthalmoscope  to  and  fro,  so  as  to  make  it  act  as  a 
prism,  the  bottom  of  the  excavation  does  not  move  as  a  whole,  but  only 
certain  portions  of  the  excavation  undergo  a  slight  displacement ;  and 
this  parallax  is  very  different  to,  and  easily  distinguishable  from  that 
met  with  in  the  glaucomatous  cup.  Moreover,  the  sudden  interruption 
of  the  over-filled  veins  at  the  edge  of  the  excavation,  which  is  so  very 
characteristic  in  the  glaucomatous  form,  is  also  wanting. 

Tlie  glaucomatous  or  pressure  excavation  (Plate  vi,  figs.  15  and  16)  is 
distinguished   by  the  following   typical  symptoms.      The   cup  is  not 
partial  and  confined  to  the  central  portion  of  the  optic  disc  as  in  the 
physiological  form,  but  it  extends  quite  to  the  edge  of  the  disc,   its 
diameter  equalling  that  of  the  latter,   and  the  lamina  cribrosa  being 
stretched  and  pushed  backwards.     Even  although  it  may  not  yet  have 
attained  a  considerable  depth,  the  edge  is  always  abrupt  and  precipitous, 
thus  differing  greatly  from  the  atrophic  excavation,  in  which  the  descent 
is  gradual  and  sloping.      The  edges  may  also  overhang  the  cup,  which 
has  undermined  the  margin  of  the  papilla.     The  disc  is  surrounded 
by  a  light  yellowish- white  ring,  which  is   due  to  the  reflection  of  light 
from  the  anterior  laminae  of  the  scleral  ring,  the  choroid  being  thinned 
and  atrophied  at  this  point.     This  zone  varies  in  width  according  to 
the  depth  of  the  excavation ;  the  deeper  and  more  advanced  the  latter, 
the  broader  and  more  marked  will  be  the  ring.     The  colour  of  the  disc 
is  also  much  changed.     Instead  of  the  yellowish-pink  appearance  of 
the  normal  disc,  the  central,  highly  shining  stippled  portion  is  sur- 
rounded by  a  deep  bluish-grey  or  bluish-green  shadow,  which  gradually 
increases  in  darkness  towards  the  periphery  of  the  disc,  where  it  may 
assume  the  appearance  of  a  dark  well-defined  rim.     On  slightly  moving 
the  mirror  or  the  object  lens,  this  shadow  will  vary  in  intensity,  more 
particularly  in  the  central  portion.     On  account  of  this  peculiar  shading 
of  the  disc,  the  latter  looks,  at  the  first  glance,  rather  arched  forward 
than  hollowed  and  excavated.     The  course  of  the  retinal  vessels  at  the 
edge  of  the  cup  is  also  very  peculiar.     They  do  not  pass,  as  in  the 
normal  eye,  straight  over  the  margin  of  the  disc  on  to  the  retina  with- 
out showing  any  curve  or  displacement ;  but  if  we  trace  their  course 
from  the  retina,  we  find  that  when  tliey  arrive  at  the  margin  of  the 
excavation,  the  dilated  veins  increase  somewhat  in  size,  and,  making  a 
more  or  less  abrupt  curve,  descend  into  the  cup  ;  at  the  point  of  curva- 
ture the  veins  also  appear  somewhat  darker  in  colour.     If  the  excava- 
tion is  deep,  the  veins  seem   to   curl  round   over  the  edge,  and  are 


EXCAVATIONS   OF  THE   OPTIC   NERVE.  391 

considerably  displaced,  so  that  the  prolongations  of  the  veins  on  the 
optic  disc  deviate  so  considerably  from  those  at  the  retinal  edge  of  the 
cup,  that  they  do  not  appear  to  belong  to  the  same  vessel.  Their  con- 
tinuity seems  interrupted,  and  this  displacement  of  the  two  portions 
may  equal  the  whole,  or  even  more,  of  the  diameter  of  the  vessel.  The 
extent  and  suddenness  of  this  displacement  vary  with  the  depth  of  the 
cup.  In  the  disc,  the  vessels  appear  indistinct  and  faded,  and  di- 
minished ia  cahbre  ;  sometimes  they  may  almost  completely  disappear, 
so  that  they  can  only  be  traced  with  difficulty.  If  the  object  lens  be 
moved,  so  as  to  give  it  the  action  of  a  prism,  a  very  marked  parallax 
will  appear  ;  the  whole  bottom  of  the  excavation  shifts  its  position,  and 
the  broad  scleral  ring  may  ^eem  to  move  over  it,  as  if  a  frame  were 
moved  over  a  picture,  the  different  portions  of  the  excavation,  however, 
shifting  their  individual  positions  but  very  slightly.  The  degree  of  the 
parallax  also  varies  according  to  the  depth  of  the  excavation.  It  is 
particularly  well  seen,  stereoscopically,  with  the  binocular  ophthalmo- 
scope. The  peculiarity  of  this  parallax  distinguishes,  in  a  marked 
manner,  the  glaucomatous  excavation  from  that  met  with  in  atrophy  of 
the  optic  nerve  ;  for  in  the  latter  case,  as  has  been  already  pointed  out, 
although  certain  portions  of  the  excavation  may  shift  their  position,  the 
bottom  of  the  cup  does  not  move  as  a  whole.  The  displacement  of  the 
vessels  in  the  glaucomatous  excavation  wiU  also  enable  us  to  distinguish 
between  this  and  the  physiological  form.  In  the  former,  the  displace- 
ment is  more  or  less  abrupt,  and  occurs  at  the  edge  of  the  disc,  whereas 
in  the  partial  or  physiological  cup,  the  displacement  or  curvature  is  not 
abrupt,  but  slight  and  gradual,  and  does  not  occur  at  the  edge  of  the 
disc,  but  within  its  area,  at  a  greater  or  less  distance  from  the  margin, 
according  to  the  extent  of  the  excavation.  Should  a  glaucomatous 
cup  supervene  upon  a  physiological  one,  we  may  at  the  outset  of  the 
disease  sometimes  observe  the  two  existing  together,  the  vessels  show- 
ing the  double  displacement — the  one  at  the  edge  of  the  physiological 
excavation  and  within  the  area  of  the  papilla,  the  other  more  abrnpt 
and  marked,  and  situated  at  the  edge  of  the  optic  disc.  But  at  a  later 
period  the  appearances  of  the  physiological  cup  are  lost,  the  latter 
becoming  involved  in  the  glaucomatous  excavation. 

In  the  majority  of  cases  it  is  not  difficult  to  distinguish  the  glauco- 
matous excavation  from  the  others,  even  before  it  has  reached  any  con- 
siderable depth ;  the  extent  of  the  cup,  the  abrupt  and  precipitous 
edges,  the  peculiar  displacement  of  the  vessels  at  its  margin,  and  the 
spontaneous  or  easily  producible  arterial  pulsation,  will  be  found  the 
surest  guides.  Where  symptoms  of  atrophy  of  the  optic  nerve  accom- 
pany the  formation  of  a  glaucomatous  excavation,  there  may  be  some 
difficulty  in  ascertaining  which  is  the  primary  affection,  more  particu- 
larly in  those  cases  in  which  atrophy  of  the  optic  nerve,   dependent 


392  DISEASES  OF   THE   OPTIC   NERVE. 

upon  cerebral  amaurosis,  has  become  complicated  with  inflammatory 
glaucoma.  In  such,  a  comparison  of  the  two  eyes,  and  a  careful  and 
searching  examination  into  the  history  of  the  case,  will  generally  clear 
up  the  difl&culty.  But  we  must  remember,  that  in  glaucomatous  exca- 
vation the  optic  nerve  often  undergoes  atrophic  changes  and  becomes 
very  white. 

At  the  commencement  of  the  glaucomatous  excavation,  the  cupping 
may  be  partial,  being  confined  to  one  portion  of  the  optic  disc ;  but  it 
will  already  show  the  typical  symptoms  of  the  pressure  excavation. 
The  optic  disc  is  perhaps  completely  surrounded  by  a  broad  scleral 
zone,  the  veins  become  somewhat  dilated  and  abruptly  displaced  at  the 
edge  of  the  cupped  portion,  and  there  is  a  bluish  shadow  at  the  peri- 
phery of  the  latter,  which  is  gradually  shaded  off  to  a  lighter  colour 
towards  the  centre. 

Von  Graefe  has  pointed  out  the  very  interesting  and  important  fact, 
that  a  glaucomatous  excavation  may  become  shallower  after  the  opera- 
tion of  iridectomy,  thus  proving  that  the  cup  depends  upon  an  increase 
in  the  intra-ocular  pressure.  The  best  cases  to  illustrate  this  fact  are 
those  in  which  acute  symptoms  have  supervened  upon  chronic  glaucoma. 
In  such  cases,  the  excavation  becomes  more  shallow  and  saucer-like,  the 
ends  of  the  vessels  less  abruptly  displaced,  and  their  interruptions  dis- 
appear, so  that  the  continuation  of  the  vessel  from  the  retina  on  to  the 
disc  can  be  distinctly  traced,  although  it  may  be  somewhat  curved. 
We  may  also  notice  that  vessels  which  were  slightly  curved  at  the  edge 
of  the  disc,  now  become  straight  again. 

4.— PIGMENTATION  OF  THE  OPTIC  NERYE. 

In  speaking  of  the  normal  appearances  presented  by  the  fundus, 
I  mentioned  that  we  frequently  meet  with  a  more  or  less  marked  and 
extensive  deposit  of  pigment  at  the  edge  of  the  disc,  and  that  this  is 
quite  physiological  and  has  no  pathological  signification.  Sometimes 
this  deposit  is  but  shght,  and  forms  a  narrow  crescent  at  one  part  of 
the  disc  ;  in  other  cases  it  is  more  considerable  in  size,  and  may  embrace 
a  larger  portion  of  the  edge  of  the  optic  nerve  entrance. 

In  rare  instances,  pigment  has  been  observed  to  be  deposited  in  the 
expanse  of  the  disc  in  cases  of  atrophy  of  the  optic  nerve.  Liebreich* 
has  published  a  case  in  which  there  was,  in  both  eyes,  atrophy  of  the 
optic  nerve  with  marked  pigment  deposit  within  the  disc,  more 
especially  in  the  left  eye.  In  the  latter  the  whole  of  the  disc,  except 
the  very  centre,  and  a  portion  of  the  outer  (temporal  side)  was  oc- 
cupied by  dense,  black  pigment.  Sometimes  there  are  noticed  small, 
bright,    superficial   particles   on  the  papilla     (after    morbid    changes, 

*  "  Annales  d'Oculistique  "  lii,  31.     Vide  also  Knapp.     "  A.  f.  O.,"  xiv,  1. 


OPAQUE   OPTIC   NER^T:   FIBRES.  393 

e.g.,   neuritis)   having    quite   the  appearance    of    cliolesterine  crystals 
(Mautliner). 

5.— TUMOURS  OF  THE  OPTIC  NERVE. 

Tumours  of  the  optic  nerve  are  of  rare  occurrence,  and  difl&cult  to 
diagnose  with  the  ophthalmoscope.  Von  Graefe*  records  a  case  in 
which  there  was  a  lai*ge  retro-ocular  orbital  tumour,  causing  a  protru- 
sion of  the  eye  to  the  extent  of  9'".  The  sight  was  completely  lost. 
With  the  ophthalmoscope,  the  retinal  veins  Avere  found  to  be  dilated  and 
tortuous,  but  the  arteries  attenuated.  At  the  inner  half  of  the  disc  (to 
which  it  was  confined)  was  noticed  a  peculiar  steep  and  abrupt  eleva- 
tion. The  latter  projected  about  1'"  above  the  perfectly  level  oiiterhalf 
of  the  disc,  and  hung  slightly  over  the  inner  edge.  Within  this 
elevated  portion,  the  substance  of  the  disc  was  of  an  opaque  greyish-red 
tint,  and  the  retinal  vessels  were  completely  hidden.  On  microscopic 
examination  by  Drs.  Recklingshausen  and  Schweigger,  it  was  found  to 
be  a  tumour  (myxoma)  of  the  optic  nerve.  In  another  case  of  orbital 
timiour  reported  by  Dr.  Jacobson,t  the  ophthalmoscope  also  revealed  a 
striking  projection  of  a  portion  of  the  optic  disc,  in  which  the  retinal 
vessels  were  lost.  The  whole  appearance  of  the  disc,  the  variations  in 
colour  of  different  portions  of  it,  as  well  as  the  course  of  the  retinal 
vessels  were  most  pecuKar.  This  was  also  found  to  be  a  myxo-sarco- 
matous  tumour  of  the  optic  nerve. 


6.— OPAQUE  OPTIC  NERVE  FIBRES. 

Amongst  the  physiological  peculiarities  of  the  retina  which  are 
sometimes  met  with,  is  one  which,  if  it  be  at  all  fully  developed,  may 
easily  be  mistaken  for  an  exudation  into  the  retina.  It  is  a  well-known 
fact,  that  in  the  human  subject  the  nerve  tubules  of  the  optic  nerve 
lose  their  neurilemma  at  the  cribriform  tissue,  passing  on  to  the  most 
anterior  portion  of  the  papilla,  and  thence  to  the  retina,  denuded  of 
their  sheath,  i.e.,  simply  in  the  form  of  transparent  axis  cylinders.  In 
certain  animals,  however,  especially  rabbits,  the  sheath  is  continued 
on  to  the  retina.  Now,  this  sometimes  also  happens  in  the  human 
subject  (as  was  first  pointed  out  by  Vii'chow),  the  optic  nerve  fibres 
retaining  their  neurilemma  for  a  short  distance  on  to  the  retina,  so  that 
the  latter,  instead  of  being  transparent,  will  at  such  points  show  a 
marked,  white  opacity.  The  ophthalmoscopic  diagnosis  of  opaque 
nerve  fibres  is  by  no  means  difficult,  and  a  little  care  and  reflection 
should  guard  any  obsei'ver  from  mistaking  these  appearances  for  morbid 
changes  in  the  i-etina.  We  notice  in  such  cases,  that  the  optic  nerve, 
*  "  A.  f.  O.,"  X,  1,  194.  t  lb.  X,  2,  55. 


394  DISEASES  OF  THE   OPTIC   NERVE. 

instead  of  being  sharply  and  clearly  defined  and  surrounded  by  trans- 
parent retina,  sliows  at  certain  points  peculiar  white,  striated,  tongue- 
like projections,  which  extend  a  httle  way  into  the  retina.  These 
patches  terminate  in  an  irregular  manner,  their  outline  showing  faint 
"  feathery  "  striee.  It  is  a  fact  of  much  diagnostic  importance,  that  the 
retina  in  the  immediate  vicinity  of  these  patches  is  perfectly  healthy 
and  transparent,  there  being  not  the  faintest  trace  of  haziness  of  the 
retina  due  to  serous  infiltration.  Whereas,  in  exudations  into  the  retina 
the  contiguous  portions  always  show  a  certain  degree  of  cloudiness. 

The  retinal  vessels  may  be  partly  or  completely  hidden  in  these 
white  patches,  which  is  especially  the  case  if  the  latter  are  considerable 
in  size.  We  then  find,  that  the  vessels  pass  from  the  centre  of  the  disc 
up  to  the  edge  of  the  opacity,  become  hidden  by  this,  and  re-appear  at 
its  periphery,  being  thence  distributed  in  a  normal  manner  over  the 
retina.  These  opacities  vary  much  in  size  and  number.  In  some  cases 
there  are  only  two  or  three  small  patches ;  in  others  there  is  one  large, 
irregular  white  figure  which  surrounds  the  greater  portion,  or  even  the 
whole  of  the  disc,  and  extends  perhaps  for  a  considerable  distance  on  to 
the  retina.  (For  a  beautiful  illustration  of  such  a  condition,  vide 
Liebreich's  Atlas,  Plate  XII.,  Figs.  1  and  2.)  Sometimes  the  little 
white  patches  may  even  show  themselves  on  the  retiria  at  some  little 
distance  from  the  disc,  not  being  in  contact  with  it,  but  separated  from 
it  by  a  portion  of  normal  retina. 

The  opacity  due  to  thickening  of  the  optic  nerve  fibres  may  be 
particularly  distinguished  from  an  inflammatory  exudation  into  the 
retina  and  optic  nerve  by  the  following  symptoms  : — 

1st.  The  optic  disc  itself  is  perfectly  normal  both  in  colour  and 
transparency,  and  the  vessels  within  its  expanse  are  also  quite  healthy 
in  appearance.  In  retinitis,  especially  where  the  morbid  products  are 
so  close  to  the  optic  nerve,  the  disc  is  always  more  or  less  hypersemic, 
indistinct,  opaque,  and  perhaps  somewhat  swollen ;  the  veins  on  its 
surface  are  dilated  and  perhaps  tortuous,  the  arteries  generally  some- 
what attenuated,  and  both  sets  of  vessels  perhaps  slightly  veiled. 
2nd.  The  opacities  caused  by  thickened  nerve  fibres  terminate,  as  has 
been  already  stated,  in  a  peculiar  manner,  like  the  fine  divisions  of  a 
tongue  of  flame.  They  end  abruptly  in  the  healthy  retina,  and  only 
here  and  there  can  a  faint  trace  of  thickened  nerve  fibre  be  followed 
for  a  very  short  distance.  3rd.  The  retina  is  perfectly  normal,  both  in 
colour  and  transparency,  quite  up  to  the  opaque  spot,  the  retinal  vessels 
are  also  absolutely  normal;  whereas  in  retinitis,  accompanied  with 
inflammatory  deposits  in  the  retina,  the  condition  is  quite  difibrent,  for 
then  we  find  that  the  retina  is  more  or  less  opaque  and  cloudy  within  a 
certain  area  around  the  exudations,  this  cloudiness  gradually  shading 
oS"  into  the  normal  retina.      The  vessels  are  also  changed,  the  veins 


OPAQUE   OPTIC   NERVE   FIBRES.  395 

being  dark,  tortuous,  and  dilated,  the  arteries  attenuated,  and  there 
are  generally  also  extravasations  of  blood  scattered  about  on  and 
between  the  vessels.  4th.  If  the  eye  is  otherwise  healthy,  the 
sight  and  the  field  of  vision  are  perfect.  If  the  opacity  is  extensive, 
the  "blind  spot,"  corresponding  to  the  area  of  the  disc,  will  be  en- 
larged. 

Mauthner*  narrates  a  very  interesting  and  peculiar  case,  in  which 
there  was  a  bifurcation  of  the  optic  nerve  fibres,  which  appeared  to  be 
collected  into  two  bundles,  the  one  passing  upwards,  the  other  down- 
wards, the  retinal  vessels  taking  the  same  course,  whilst  on  the  inner 
and  outer  portion  of  the  disc  there  were  no  vessels.  The  fibres  were 
devoid  of  their  sheath,  and  hence  their  tint  was  not  brilliantly  white, 
but  their  situation  and  course  were  very  marked  and  distinct,  on  account 
of  the  close  super-imposition  of  the  individual  fibres,  which  rendered 
the  upper  and  lower  margin  of  the  papilla  quite  lost  and  indistinct. 

*  Op.  cit.,  p.  267. 


1/ 


Chapter  X. 

AMBLYOPIC   AFFECTIONS    (AMAUEOSIS    AND 
AMBLYOPIA). 


Under  the  vague  term  "amaurosis"  were  formerly  included  all 
kinds  of  intra-ocular  diseases  that  were  not  distinguishable  with  the 
naked  eye,  but  since  the  discovery  of  the  ophthalmoscope  has  revealed 
the  true  nature  of  the  diseases  of  the  inner  tunics  of  the  eye  and  of  the 
optic  nerve,  we  are  able  to  confine  the  term  "  amaurosis "  to  very 
narrow  limits.  Indeed  it  is  of  great  practical  importance,  that  a 
definite  understanding  should  be  arrived  at,  as  to  what  diseases  are  to 
be  included  in  the  group  of  "  amblyopic  afiections."  Thus  only  can  we 
remedy  the  confusion  which  still  exists,  from  the  fact  that  some  writers 
apply  the  name  amaurosis  indiscriminately  to  all  cases  of  total  blindness 
dependent  upon  deep-seated  intra-ocular  afiections,  whilst  others  give  tc 
it  a  more  limited  signification,  and  confine  it  to  the  loss  of  sight  depen- 
dent upon  intra-cranial  disease.  I  think,  therefore,  that  Yon  Graefe's 
signification  should  be  universally  adopted.  He  excludes  from  the  term 
"  amblyopic  afiections  "  (amblyopia  and  amaurosis)  all  disturbances  of 
sight  dependent  upon  material,  perceptible  changes  in  the  refractive 
media,  in  the  internal  tunics  of  the  eye,  on  neuro- retinitis  and  embolism 
of  the  central  artery  of  the  retina.*  It  may  be  questioned  whether  we 
should  exclude  cases  of  optic  neuritis  from  this  group,  as  they  are 
o-enerally  due  to  intra-cranial  disease,  and  but  too  frequently  pass  over 
into  consecutive  atrophy  of  the  optic  nerve  and  retina,  and  more  or  less 
complete  blindness.  But  even  in  such  cases,  I  think  it  would  be  better 
and  more  definite  to  term  such  blindness,  amaurosis  from  optic  neuritis, 
just  as  we  should  speak  of  amaurosis  (or  amblyopia  as  the  case  may  be) 
from  retinitis  pigmentosa,  from  glaucoma,  or  embolism  of  the  central 
artery  of  the  retina ;  in  fact  that  we  should  strictly  confine  the  term 
amaurosis  to  cases  of  bhndness  from  primary  atrophy  (degenerative 
atrophy)  of  the  optic  nerve,  and  that  of  amblyopia  (in  a  special  sense), 
to  impairment  of  vision  produced  by  irregularities  in  the  circulation  or 
the  nervous  system,  which  may  lead  in  the  end-  to  primary  atrophy  of 
the  optic  nerve. 

*  Vide  Von  Graefe's  Lectures  on  "  Amblyopic  Affections,"  "  Kl.  M.,"  1865.  An 
able  translation  of  these  important  and  valuable  Lectures  by  Mr.  Z.  Laurence  will 
be  found  in  the  "  Ophthalmic  Review,"  ii,  232. 


AMAUROSIS.  ol)7 

Amblyopic  fiffections  are  also  sometimes  classified  according  to  the 
degree  of  impairment  of  sight. 

Liebreich*  distinguishes  three  different  forms — 1st.  Amaurotic 
amhl)/oj)ia,  in  which  the  sight  is  so  much  deteriorated  that  even  large 
objects  are  only  distinguished  with  difficulty,  or  the  patient  is  not 
able  to  guide  himself.  2nd.  Amaurosis,  in  this  condition  even  large 
objects  can  no  longer  be  distinguished,  there  being  no  qualitative  but 
only  quantitative  perception  of  light,  which  may  exist  either  in  the 
whole  or  only  a  part  of  the  field  of  vision.  3rd.  Absolute  amaurosis, 
where  the  patient  has  not  the  faintest  power  of  distinguishing  between 
light  and  darkness. 

In  examining  the  sight  of  cases  of  amaurosis  and  arablyopia,  it  is 
very  important  to  ascertain  the  condition  of  the  field  of  vision  with  the 
greatest  accuracy.  In  these  diseases,  it  does  not  suffice  to  examine  the 
field  by  daylight,  because  slight  contractions  or  interruptions  may  thus 
easily  escape  detection,  which  will  however  become  at  once  apparent  if  the 
field  is  tested  by  a  more  subdued  light,  for  which  purpose  Von  Grraefe's 
graduated  disc  of  light  will  be  found  the  best.  The  mode  and  extent 
of  the  contraction  or  interruption  of  the  field  of  vision,  are  of  great 
importance  in  enabling  us  to  form  our  prognosis  as  to  the  risk  of  a  total 
loss  of  vision,  or  the  chances  of  an  improvement,  or  even  a  restoration 
of  the  sight. 

In  the  following  description  of  the  different  kinds  of  contraction 
and  interruption  of  the  visual  field,  and  their  bearing  upon  the  prognosis 
as  to  the  ultimate  condition  of  the  sight,  etc.,  I  have  mainly  followed 
the  views  of  Von  Graefe  as  expressed  in  the  above-mentioned  lectures 
on  amblyopic  afi'ections  ;  indeed  he  is  the  first  writer  who  has  attempted 
to  lay  down  anything  like  definite  rules  with  regard  to  the  chief  points 
that  should  influence  our  prognosis  in  this  class  of  diseases.  This,  in 
fact,  could  only  be  done  by  one  who  had  for  many  years  closely  watched 
the  course  of  a  vast  number  of  cases,  and  carefully  studied  their 
minutest  details.  A  mere  hypothetical  generalization,  not  founded 
upon  absolute,  sufficient,  and  closely  scrutinized  data  would  be  simply 
valueless. 

Several  different  forms  of  contraction  of  the  field  of  vision  may  be 
observed  in  amblyopic  affections. 

The  contraction  frequently  commences  at  the  temporal  side  of  the 
field  of  vision  (the  nasal  portion  of  the  retina  being  the  first  to  suffer), 
and  from  thence  either  passes  on  laterally  towards  the  centre,  or  along 
the  periphery  in  an  upward  and  do-^Tiward  direction,  extending  finally 
towards  the  nasal  side  ;  and  then,  when  the  whole  periphery  of  the  field 
has  become  impaired,  the  contraction  advances  concentrically  towards 
the  axis  of  vision.  The  outlines  of  both  these  forms  of  contraction  of  the 
*  "  Nouveau  Dictionnaire  de  Med.  ct  de  Cliir.  prat.,"  785. 


398 


AMBLYOPIC   AFFECTIONS. 


field  are  often  very  irregular  and  undnlatory.  The  contraction  of  the 
field  in  cases  of  amaurosis  generally  commences  at  the  temporal  side, 
but  this  is  not  always  the  case,  for  it  may  begin  at  the  nasal.  Whereas, 
in  the  contraction  met  with  in  glaucoma,  it  is  a  very  characteristic 
feature  that  as  a  rule  it  commences  at  the  nasal  side  (the  outer  por- 
tion of  the  retina  becoming  first  impaired).  We  occasionally  find  that 
some  time  after  the  first  eye  has  become  affected  (and  perhaps  even 
amaurotic),  a  gradually  progressive  contraction  of  the  field  shows 
itself  in  the  second  eye,  commencing  perhaps  at  a  point  quite  sym- 
metrical to  that  in  which  the  contraction  began  in  the  eye  originally 
affected.  Such  cases  afford  a  most  unfavourable  prognosis,  more  espe- 
cially if  the  central  vision  is  greatly  impaired,  or  already  perhaps  sunk 
below  that  of  the  eccentric  portion  of  the  retina,  for  these  symptoms 
indicate  but  too  surely  a  progressive  atrophy  of  the  optic  nerve. 

The  contraction  of  the  field  may  be  equilateral  in  both  eyes,  e.g.,  the 
right  half  of  each  field  may  be  wanting,  and  the  line  of  demarcation 
between  this  and  the  normal  half  of  the  field  be  quite  sharply  defined, 
and  situated  in  the  axis  of  vision.  This  is  termed  equilateral  or 
homonymous  hemiopia,  on  account  of  the  corresponding  halves  (the 
right  or  left  as  the  case  may  be)  being  affected.  The  nature  of  this 
condition  is  self-evident,  when  we  remember  the  anatomical  relations 
of  the  optic  nerves  to  each  other,  and  the  fact  that  their  fibres  decussate 
at  the  optic  commissure  (chiasma)  in  such  a  manner,  that  the  right 

optic  nerve  supplies  the  right 
half  of  each  retina  (the  temporal 
side  in  the  right  eye,  the  nasal  in 
the  left),  and  the  left  optic  nerve 
the  left  half.  A  glance  at  fig.  65 
will  explain  this  arrangement. 

This  figure  represents  the  com- 
missure of  the  optic  nerves  and 
their  prolongation  to  the  retina. 
R  the  right  optic  nerve.  L  the 
left  optic  nerve. 
If,  therefore,  a  tumour  or  an  haemorrhagic  effusion  compresses  the 
right  optic  nerve  on  the  central  side  of  the  conamissure,  in  such  a 
manner  as  completely  to  destroy  its  conductibility,  the  right  half  of 
each  retina  will  be  impaired,  and  consequently  the  left  half  of  each 
field  of  vision  be  wanting.  But  if  the  compression  is  limited  to  the 
commissure,  affecting  only  the  crossed  fibres,  and  leaving  the  lateral 
ones  unimpaired,  the  appearances  will  be  different,  for  then  the  nasal 
half  of  each  retina  will  be  affected,  and  the  temporal  half  of  each  field 
be  wanting.  In  such  cases,  however,  the  hemiopia  is  not  so  sharply 
defined  as  in  the  equilateral  form,  for  there  is  generally  a  more  or  less 


AMAUROSIS.  399 

broad  lino  of  transition,  in  whicli  the  defective  portion  of  the  field 
passes  over  gradually  into  the  healtliy  part.  The  scat  of  tlic  disease 
may  not,  however,  be  confined  to  the  commissure,  but  be  situated 
principally  in  front  of  or  behind  the  latter.  This  may  be  suspected  if 
other  symptoms  co-exist  with  the  hemiopia,  such  as  paralysis  of  other 
nerves,  hemiplegia,  impairment  of  the  mental  functions,  etc.  It  will 
be  seen,  hereafter,  that  the  prognosis  is  less  favourable  in  the  temporal 
than  in  the  equilateral  hemiopia.  It  is  extremely  rare  to  meet  with 
hemiopia  of  the  upper  or  lower  halves  of  the  field,  and  the  real  nature 
of  such  cases  is  at  present  quite  unexplained. 

If  the  cause  of  the  compression  is  situated  at  the  distal  end  of  the 
optic  nerve,  i.e.,  after  the  crossing  of  the  fibres  in  the  commissure,  of 
coui'se  the  corresponding  eye  is  alone  aff'ected. 

In  addition  to  the  contraction  of  the  field  of  vision,  we  often 
meet  with  interruptions  in  its  continuity,  which  appear  in  the  form 
of  dark,  in-egular  clouds  or  spots  before  the  patient's  eyes.  These 
"  scotomata "  (as  they  are  called)  may  be  situated  in  or  near  the 
centre  of  the  field,  or  at  its  periphery.  On  examining  the  field  in 
cases  of  scotomata,  we  find  that  within  a  certain  area  there  is  a  more 
or  less  considerable  gap,  in  which  the  object  becomes  indistinct,  or 
even  lost.  If  the  scotoma  is  situated  in  the  axis  of  vision,  it  of  course 
produces  great  impairment  of  sight,  and  the  patient  often  squints  in  a 
certain  direction,  in  order  that  the  rays  from  the  object  may  fall  upon 
a  more  sensitive  (in  this  case  eccentric)  portion  of  the  retina.  Whereas, 
if  the  interruption  occurs  at  the  periphery  of  the  field,  and  is  only  incon- 
siderable iui  size,  it  is  generally  altogether  overlooked  by  the  patient. 

These  scotomata  generally  make  their  appearance  very  suddenly ; 
sometimes,  howevei*,  a  few  weeks  elapse  before  they  become  fully  deve- 
loped. They  are  not  unfrequently  met  with  after  exhausting  general 
diseases,  and  after  great  mental  emotions,  and  are  accompanied,  perhaps, 
by  cutaneous  insensibility  to  pain.  According  to  Von  Graefe  they 
occur  most  frequently  in  young  persons,  and  are  never  seen  in  connec- 
tion with  hsemorrhagic  diseases  of  the  brain.  Their  cause  is  at  present 
unknown.  In  cases  of  peripheral  antesthesia  of  the  retina,  we  often 
meet  with  the  interesting  phenomenon  that  the  phosphenes  continue  to 
exist  in  portions  of  the  retina  which  are  quite  insensitive  to  light,  and 
this  is  of  prognostic  importance,  as  it  does  not  occur  in  amaurosis.  The 
sight  is  generally  very  considerably  affected,  and  may  finally  become 
quite  lost,  so  that  the  patient  cannot  distinguish  between  light  and 
dark. 

In  cerebral  amaurosis,  the  pupil  is  generally  somewhat  dilated  and 
sluggish,  or  immoveable  and  large,  if  the  eye  is  quite  blind.  If  the  pupil 
is  dilated  to  its  fullest  extent,  so  that  the  narrow  rim  of  iris  is  hardly 
discernible,  we  must  assume  that  there  co-exists  an  irritation  of  the 


400  a:mblyopic  affections. 

sympatlietic  fibres,  causing  a  contraction  of  the  dilator  pupillae.  If  one 
eye  only  is  affected,  we  often  find  tliat  its  pupil  is  dilated  and  immove- 
able under  tlie  stimulus  of  light  when  the  other  eye  is  closed,  but  that 
it  at  once  contracts  consentaneously  with  the  pupil  of  its  fellow,  when 
the  latter  is  uncovered.  This  fact  may  prove  of  use  in  detecting  the 
simulation  of  blindness  in  one  eye  by  the  dilatation  of  the  pupil  by 
atropine,  when  of  course  this  consentaneous  action  could  not  occur. 
Great  importance  cannot,  however,  be  attached  in  cases  of  amaurosis 
to  the  behaviour  of  the  pupil,  for  we  sometimes  find  that  even  in  com- 
plete blindness  it  retains  its  activity.  In  spinal  amaurosis,  the  pupil  is 
unusually  and  perhaps  irregularly  contracted  (oval),  and  acts  but  very 
sluggishly  and  impei-fectly  upon  the  application  of  atropine.  The  great 
contraction  is  due  to  the  paralysis  of  the  sympathetic  fibres. 

The  ophthalmoscopic  symptoms  of  cerebral  and  cerebro-spinal  amau- 
rosis, consist  in  certain  changes  in  the  appearance  of  the  optic  nerve, 
indicative  of  its  progressive  atrophy.  Care  must,  however,  be  taken 
not  to  mistake  simple  anaemia,  or  blanching  of  the  disc,  for  incipient 
atrophy.  The  small  nutritive  vessels,  which  are  distributed  upon  the 
expanse  of  the  disc,  disappear,  and  this  partly  produces  the  white 
colour ;  whilst  the  vessels  distributed  over  the  retina  may  retain  their 
normal  calibre,  even  when  the  optic  nerve  is  quite  atrophied,  but 
generally  they  soon  become  attenuated.  The  symptoms  of  atrophy  of 
the  optic  nerve  have  already  been  fully  described  (p.  385). 

We  have  now  to  turn  our  attention  to  the  various  causes  which  may 
produce  cerebral  and  cerebro-spinal  amaurosis.  But  this  subject  is  far 
too  extensive  for  the  scope  of  this  work,  and  I  must  therefore  confine 
myself  to  giving  a  mere  outline  of  the  principal  causes,  and  must  refer 
the  reader  for  fuller  information  to  special  works  and  articles  upon 
this  subject.  Amongst  these  I  must  especially  recommend  those  of 
Von  Grraefe,  Hughlings  Jackson,  Hutchinson,  Ogle,  Galezowski,  etc. 

It  must,  however,  be  candidly  confessed  that  we  cannot  diagnose 
the  special  cerebral  cause,  or  localise  its  seat,  simply  from  the  ophthal- 
moscopic symptoms  presented  by  the  optic  nerve.  In  order  to  aid  and 
guide  us  in  arriving  at  a  conclusion  as  to  the  cause  and  its  situation,  other 
local  and  general  symptoms  must  be  searched  for.  But,  even  with  their 
aid,  we  often  fail  to  determine  these  points  with  anything  approaching 
to  certainty,  and  may  find,  on  post  mortem  examination,  that  we  have 
been  quite  mistaken.  Indeed  we  sometimes  meet  with  cases  of  simple 
progressive  atrophy  of  the  optic  nerve,  leading  to  blindness,  in  which 
it  is  quite  impossible  to  detect  any  special  cause,  either  cerebral,  spinal, 
or  constitutional.  On  the  other  hand,  the  trunk  of  the  optic  nerve  may 
be  seriously  implicated  in  the  intra-cranial  disease,  without  the  sight 
being  in  the  least  affected.* 

*  "  A.  f.  O.,"  xii,  2,  p.  111. 


AMAUROSIS.  401 

Still  the  ophthalmoscope  proves  of  immense  use  to  the  physician  in 
the  practice  of  his  art,  and  may  often  lead  him  to  the  discovery  of 
diseases  wliich  he  woiild,  Avithont  it,  have  passed  over,  or  misinter- 
preted. 

As  I  have  already  mentioned  the  various  affections  of  the  brain 
which  may  produce  optic  neui-itis,  I  shall  now  only  consider  those 
which  may  give  rise  to  progressive  atrophy  of  the  optic  nerve. 

Meningitis  of  the  base  of  the  brain  is  a  very  frequent  cause  of 
disease  of  the  optic  nerve.  The  symptoms  of  acute  meningitis  are 
generally  so  marked  and  characteristic  that  the  diagnosis  is  not  difficult, 
but  it  is  different  with  the  chronic  form,  the  course  of  which  is  often 
very  insidious,  and  its  symptoms  masked  and  indistinct.  But  its 
presence  may  be  suspected,  if  there  are  febrile  attacks  accompanied  by 
violent  and  recurrent  paroxysms  of  headache,  severe  vomiting  and  retch- 
ing, unconsciousness,  and  sensitiveness  of  the  cranium  to  palpation. 
Moreover,  as  the  inflammation  of  the  meninges  is  generally  somewhat 
diffuse,  we  find  that  other  cerebral  nerves  become  affected,  being  either 
paralysed  or  in  a  state  of  irritation.  Thus,  we  sometimes  find  that  some 
of  the  muscles  of  the  eye  are  paralysed,  whilst  others  are  in  a  state 
of  spasmodic  contraction  (Graefe).  The  inflammation  of  the  meninges 
may  extend  fi'om  the  membranes  to  the  cortical  substance  of  the  brain, 
perhaps  to  a  considerable  depth,  reaching,  according  to  L.  Meyer,* 
even  to  the  optic  thalami. 

With  regard  to  the  headaches  which  may  occur  in  cases  of  ambly- 
opia, we  must  be  on  our  guard  not  to  attribute  them  always  to  some 
cerebral  affection  ;  for,  as  Yon  Graefe  has  pointed  out,  they  are  often 
only  due  to  the  failing  sight,  and  are  produced  by  the  intent  endeavour 
of  the  patient  still  thoroughly  to  realize  the  visual  impressions.  On 
account  of  this,  there  occur  disturbances  of  sensibihty  akin  in  nature  to 
those  which  are  met  with  in  double  vision,  circles  of  diffusion  upon  the 
retina,  etc.  If  the  headache  be  simply  due  to  this  cause,  cessation  from 
work  will  rapidly  cure  it ;  for  it  can  be  easily  understood  that  its 
intensity  may  be  materially  increased  by  any  cause  that  produces  con- 
gestion of  the  brain  or  the  eye,  such  as  stooping,  etc. 

Acute  meningitis,  more  especially  the  tubercular  form,  generally 
gives  rise  to  optic  neuritis,  and  this  often  ensues  rapidly  upon  the  out- 
break of  the  cerebral  affection ;  whereas,  in  the  chronic  form,  the  optic 
nerve  often  remains  altogether,  or  for  a  long  time,  unaffected,  and  then 
it  •cm.dergoes  progressive  atrophy,  its  nutrition  becoming  impaii^ed  by 
the  chronic  congestion  of  the  brain  and  meninges. 

Chronic  Periostitis  of  the  base  of  the  brain  may  also  produce 
amaurosis. 

*  L.  Meyer,  "  Centralblatt  fiir  Med.  Wisseusch.,"  Nos.  8,  9,  10,  1867. 

2   D 


402  AMBLYOPIC   AFFECTIONS. 

Tumours  within  the  brain  may  cause  progressive  atrophy  of  the 
optic  nerve,  either  by  the  latter  becoming  directly  implicated  in  the 
morbid  process,  and  its  nervous  elements  destroyed,  or  by  its  being 
compressed,  stretched,  or  pushed  aside  by  the  tumour,  so  that  its 
conductibility  and  its  nutrition  are  greatly  interfered  with ;  but  the 
impairment  of  nutrition  may  also  be  due  to  pressure  upon  the  blood- 
vessels of  the  optic  nerve.  Although  sarcomatous  and  carcinomatous 
tumours  are  the  most  frequent  morbid  growths,  we  must  include  other 
neo-plasms,  such  as  masses  of  tubercle,  sypjiilitic  gummata,  exostoses, 
etc.  Such  morbid  growths  may  be  situated  at  the  base  of  the  brain  or 
within  its  substance.  Their  diagnosis  is  very  uncertain  and  obscure, 
except  other  general  or  local  symptoms  co-exist,  which  may  aid  us  in 
determining  the  probable  nature  and  seat  of  the  cerebral  disease.  Thus 
in  equilateral  hemiopia  (say  of  the  left  half  of  the  visual  field)  we  should 
suspect  that  a  tumour  or  hsemorrhagic  effusion  is  pressing  upon  the  right 
optic  nerve. 

If  the  temporal  half  of  each  field  is  impaired,  the  crossed  fasciculi  of 
the  nerves  are  involved,  and  the  seat  of  the  disease  is  at  the  commissure. 
In  such  cases  the  impairment  of  vision  is  often  very  rapid,  the  sight 
being  perhaps  utterly  destroyed  within  a  few  days.  The  contraction  of 
the  visual  field  begins  at  the  periphery  of  the  temporal  side  and  extends 
up  to  or  beyond  the  centre,  so  that  finally  only  a  slight  glimmer  of  light 
may  be  left  at  the  nasal  side.  If  the  cerebral  tumour  is  very  slow  in 
its  development,  the  brain  substance  and  the  nerves  may  gradually 
accommodate  themselves  to  its  growth,  and  there  may  only  periodically 
arise  some  compression  of  the  vessels  at  the  base  of  the  brain,  which, 
setting  up  distui'bance  in  the  intra-cranial  circulation,  will  give  rise  to 
ephemeral  hemiplegia,  ischasmia,  and  fainting  or  epileptoid  fits.  But 
symptoms  of  paralysis  of  the  cerebral  nerves  may  supervene  if  the 
tumour  pervades,  irritates,  or  presses  upon  the  nerve  substance,  or 
if  the  vessels  become  compressed  and  the  nutrition  of  the  nerves 
impaired.* 

Tumours  in  the  cerebellum  nearly  always  produce  blindness  (generally 
from  optic  neuritis)  by  setting  up  a  general  disturbance  (Hughhngs 
Jackson),  whereas  abscess  of  the  cerebellum,  as  a  rule,  does  not  do  so 
on  account  of  its  hmited  extent  and  effect. 

Cerehral  hceinorrhage  may  be  suspected  if  the  amaurosis  comes  on 
very  suddenly  ;  thus  sudden  equilateral  hemiopia  of  the  left  side 'would 
make  us  suspect  hcemorrhage  in  the  right  hemisphere.  Such  equilateral 
contractions  of  the  field  often  remain  behind  in  persons  who  have  been 
affected  with  an  apoplectic  fit.  Loss  of  the  right  side  of  the  field  is  more 
irksome  than  that  of  the  left,  more  especially  in  reading,  as  the  patient 
cannot  read  so  easily  and  rapidly  on  account  of  his  not  being  able  to 
*  "  Kl.  Monatsbl.,"  1865,  p.  259. 


AMAUROSIS.  403 

foresee  the  words  (Graefe).  In  slight  degrees  of  cerebral  hjEmorrhagc, 
the  sight  is  often  quite  unaffected.  Hemiopia  may,  however,  be  also 
produced  by  temporary  affections  of  the  nerve  trunk,  e.g.,  syphiHs. 

Senile  softening  of  the  brain  is  not,  as  a  rule,  accompanied  by 
amaurosis,  but,  of  course,  the  atrophic  changes  in  the  brain  may  extend 
to  the  optic  nerves,  the  nutrition  of  the  latter  becoming  impaired  on 
account  perhaps  of  the  disease  of  the  vessels. 

Epilepsy  may  produce  amaurosis  when  it  is  due  to  some  disease  of 
the  brain,  for  instance  meningitis,  for  epilepsy  must  be  looked  upon  as 
a  symptom  and  not  as  a  disease. 

In  diseases  of  the  spinal  cord,  more  especially  chronic  myeHtis  and 
locomotor  ataxy,  amaurosis,  from  progressive  atrophy  of  the  optic  nerves, 
is  not  unfrequently  met  "wdth.  But  it  hardly  ever  makes  its  appearance 
in  locomotor  ataxy  until  a  late  period  of  the  disease  of  the  spine,  long 
after  the  impairment  of  the  mobihty  and  sensibility  of  the  lower  limbs, 
and  the  paralytic  affections  of  the  muscles  of  the  eye,  the  latter  often 
being  amongst  the  first  symptoms  of  the  spinal  disease.  In  some  very  rare 
instances,  the  atrophy  of  the  optic  nerves  has  preceded  by  a  long  period 
(several  years)  the  first  symptoms  of  spinal  disease  (Graefe).  This  late 
occurrence  of  amaurosis  is  explained  by  the  fact  that  the  degeneration 
ascends  from  the  vertebral  canal  to  the  cavity  of  the  cranium.  Ambly- 
opia often  occTirs  at  the  commencement  of  the  spinal  affection,  and  a 
careful  examination  as  to  the  true  nature  of  this  impairment  of  vision 
should  be  made,  for  it  may  only  be  due  to  a  loss  of  the  power  of  accom- 
modation from  paralysis  of  the  cihary  muscle,  and  be  not  at  all  de- 
pendent upon  any  disease  of  the  optic  nerve.  A  want  of  care  in  the 
examination  as  to  the  true  cause  of  such  amblyopisG,  has  led  to  much 
confusion  amongst  writers  upon  this  subject.  In  cases  in  which  the 
atrophy  of  the  optic  nerve  is  dependent  upon  locomotor  ataxy,  the 
former  may  remain  stationary  for  a  few  weeks  and  then  again  progress 
(Graefe). 

The  affection  of  the  optic  nerve  in  diseases  of  the  spine  is  probably 
due  to  a  lesion  of  the  great  sympathetic,  through  its  communication 
with  the  anterior  roots  of  the  spinal  nerves. 

In  some  cases  simple  atrophy  of  the  optic  nerve  exists  for  a  long 
time  without  any  appreciable  cause,  or  the  appearance  of  any  symptoms 
indicative  of  a  cerebral  or  spinal  lesion  ;  and,  even  after  death,  nothing 
is  perhaps  found  except  atrophy  of  the  optic  nerves  or  atrophy  of  those 
parts  of  the  brain  which  are  continuous  with  the  optic  nerve.  In  some 
of  these  cases,  however,  insanity  may  supervene.  And  this  brings  us 
to  a  very  important  point,  viz.,  the  great  use  of  which  the  ophthalmo- 
scope is  likely  to  prove  to  the  alienist  in  establishing  the  study  of  in- 
sanity upon  a  more  positive  basis.*     In  England  we  are  almost  entirely 

*  For  further  information  I  would  particularly  recommend  Dr.  Leber's  van' 

2   D  2 


404  AMBLYOPIC   AFFECTIONS. 

indebted  to  Dr.  Allbutt  for  our  knowledge  of  this  subject,  and  I  would 
refer  tlie  reader  to  his  valuable  and  interesting  paper,  entitled  "  On  the 
state  of  the  Optic  Nerves  and  Retinae  as  seen  in  the  Insane,"  read  before 
the  Roy.  Med.  Chir.  Society,  February  25,  1868.  In  this,  he  mentions 
that  in  general  paralysis  of  the  insane,  atrophy  of  the  optic  nerve  is 
constantly  found,  and  is  coramonly  accompanied  by  atrophy  of  the 
olfactory  nerves.  It  is  not  distinctly  seen  till  the  end  of  the  first  stage, 
as  it  slowly  travels  down  from  the  optic  centres,  and  it  is  in  relation 
with  the  state  of  the  pupil,  which  is  contracted  in  the  early  stage  and 
dilated  in  the  fatty  atrophic  stage. 

In  mania,  the  ophthalmoscope  often  reveals  symptomatic  changes. 
In  dementia  organic  disease  and  affection  of  the  eye  generally  occur 
together. 

In  idiots  atrophy  of  the  optic  nerve  is  of  frequent  occurrence.  Out 
of  twelve  cases,  it  was  found  of  a  marked  character  in  five  ;  one  was 
changing,  and  two  were  noted  as  doubtful. 

We  have  now  to  consider  the  prognosis  which  may  be  made  in  cases 
of  amaurosis  or  amblyopia,  as  to  whether  the  impairment  of  vision  will 
improve,  remain  stationary,  or  become  permanently  lost.  In  framing 
such  a  prognosis,  we  must  be  especially  guided  by  the  mode  of  attack, 
the  condition  of  the  field  of  vision,  and  the  appearances  presented  by 
the  optic  nerve.  The  nature  of  the  primary  disease  which  has  caused 
the  afiection  of  the  eye  must  naturally  also  be  taken  into  anxious  con- 
sideration. For  the  prognosis  will,  of  course,  be  materially  influenced 
by  the  fact,  that  the  intra-cranial  afiection  is  of  a  kind  that  permits  of 
resolution  or  amelioration  through  the  absorption  of  morbid  products, 
or  hcemorrhagic  efiusion,  or  the  amendment  of  iri'egularities  in  the 
circulation. 

If  atrophy  of  the  optic  nerve  has  already  set  in,  the  prognosis  as  to 
the  arrest  of  the  disease  must  be  very  guarded,  as  in  such  cases  there 
is  always  a  great  tendency  to  progression,  and  termination  in  absolute 
blindness.  But  this  is  not  necessarily  always  the  case,  and  it  would 
be  committing  a  grave  error  to  irrevocably  conderan  an  eye,  simply 
because  the  optic  nerve  shows  symptoms  of  commencing  atrophy.  The 
state  of  the  field  of  vision  is  our  best  guide  in  such  cases. 

If  the  loss  of  sight  has  occurred  with  great  suddenness  and  rapidity, 
the  prognosis  need  not  necessarily  be  bad,  for  we  occasionally  meet 
with  cases  in  which  great  improvement,  or  even  complete  restoration 
of  sight  takes  place  after  its  sudden  loss.  Sudden  eqviilateral  hemi- 
opia  is  generally  due  to  haemorrhagic  efiusions  (apoplexies),  which  is 
seldom  the  case  in  double  central  scotomata.     Von  Graefe*  considers 

intereBting  paper  "  On  Groy  Degeneration  of  the  Optic  Nerve,"  "  A.  f.  O.,"  xiv,  2, 
177  ;  also  Dr.  Westpliiirs  important  papers  in  the  "  Arcliiv.  fiir  Psyehiatrie." 
*  "Kl.  Monatsbl.,"  1865,  149. 


AMAUROSIS.  405 

that  the  prognosis  of  sudden  amaurosis  is  better  in  children  than  in 
adults.  He  also  states  that  the  best  prognosis  is  furnished  by  those 
cases  in  which  the  sudden  loss  of  sight  is  the  result  of  mental  shock  ; 
also  if  the  phosphenes  continue  to  exist  in  the  blind  retina,  and  com- 
plete darkness  proves  beneficial.  This  form  of  anaesthesia  is  often 
associated  with  cutaneous  insensibility  to  pain,  and  is  perhaps  referable 
to  vaso-motor  action. 

The  prognosis  is  also  inclined  to  be  favourable,  if  the  disease  has 
remained  stationary  for  some  length  of  time,  for  although  the  dangerous 
forms  of  amaurosis  likewise  halt  in  their  progress,  yet  this  interruption 
does  not  extend  beyond  a  few  weeks  or  months,  when  they  again  pro- 
gress. The  former  cases  often  depend  upon  a  combination  of  delete- 
rious causes,  such  as  alcohol,  tobacco,  dissipation  of  every  kind,  over- 
work of  the  eyes  and  brain,  irregularities  in  the  digestive  organs  or 
the  uterine  system. 

The  prognosis  is  bad,  if  the  atrophy  of  the  optic  nerve  is  of  slow 
development  and  manifests  a  persistent,  though  perhaps  tardy,  progress. 

When  the  atrophy  of  the  nerve  cannot  be  traced  to  any  particular 
cause,  but  appears  to  be  a  disease  per  se,  the  prognosis  is  generally  also 
very  unfavourable. 

In  those  cases  in  which  the  condition  of  the  visual  field  is  quite 
normal  (even  after  the  affection  has  existed  for  several  months),  and  the 
acuity  of  vision  has  not  sunk  considerably  (only  to  one-sixth  or  one- 
tenth),  we  may  decidedly  regard  the  disease  as  not  being  due  to  pro- 
gressive atrophy.  The  impaii'ment  of  vision  may  not,  however,  undergo 
much  improvement. 

With  regard  to  the  pi'ognosis  afforded  by  the  different  forms  of 
contraction  and  interruption  of  the  visual  field,  we  may  briefly  state, 
that  it  is  more  favourable  when  it  is  equilateral  with  a  sharply-defined 
line  of  demarcation  than  when  it  is  concentric,  or  its  edges  (in  the 
lateral  form)  are  undefined  and  irregular.  Indeed,  patients  affected 
with  equilateral  hemiopia  never  become  absolutely  blind,  except  the 
disease  extends  to  the  commissure,  or  some  other  cerebral  affection 
sapervenes.*  Such  patients  often  enjoy  excellent  central  vision,  being 
able  to  read  the  finest  print,  and  the  affection  frequently  remains  unaltered 
for  a  very  long  time.     I  have  cases   still  under  supervision  in  which 

*  Von  G-raefe  says  :  "  Total  blindness  in  cases  of  unilateral  brain  disease  can 
only  ensue  (1),  when  the  other  hemisphere  likewise  becomes  the  seat  of  disease ; 
(2),  when  fresh  effusions  in  the  hemisphere  originally  affected  occasion  diffuse  cere- 
bral disease,  haply  thi-ough  anaemia  cerebri ;  (3) ,  when  a  basilar  affection  supervenes, 
directly  affecting  the  trunks  of  the  optic  nerves ;  (4),  when  some  encroachment  on 
the  space  of  the  cerebral  cavity  results  in  compression  of  the  sinus  cavernosus  with 
consequent  venous  incarceration  of  the  papillae;  (5),  when  propagated  encephalo- 
meningitis  leads  to  neuritis  descendens."  ("  Kl.  Monatsbl.,"  1865,  220  ;  "  Ophth. 
Keview,"  ii,  359.) 


406  AMBLYOPIC   AFFECTIONS. 

equilateral  hemiopia  has  existed  for  some  years,  and  the  patients  are 
still  able  to  read  perfectly,  nor  has  the  condition  of  the  eye  changed,  nor 
have  any  other  symptoms  shown  themselves. 

The  most  dangerous  cases  are  those,  in  which  irregular  contractions 
of  the  field  of  vision  occur  either  simultaneously  in  both  eyes,  or  in 
quick  succession.  Also  those,  in  which  the  condition  of  the  one  eye 
being  already  very  bad  (the  degree  of  its  central  vision  being  perhaps 
even  less  than  the  eccentric),  the  second  eye  becomes  afiected  in  an 
exactly  similar  manner,  the  contraction  of  its  visual  field  commencing 
at  a  point  symmetrical  to  that  at  wliich  it  began  in  the  first  eye. 

Central  scotomata  never  indicate  progressive  atrophy,  if  the  periphery 
of  the  visual  field  is  normal.  But  if  they  have  existed  unaltered  for 
several  weeks,  and  the  optic  nerve  begins  to  show  symptoms  of  com- 
mencing atrophy,  a  restitution  ad  integrum  can  no  longer  be  expected. 
If  the  central  portion  of  the  retina  maintains  its  superiority  of  vision 
over  the  outlying  parts  (so  that  the  patient  can  see  through  the 
scotoma),  the  prognosis  is  always  better  than  when  the  reverse  obtains. 
If  the  peripheral  portion  of  the  field  of  vision  beyond  the  scotoma  is 
impaired,  progressive  atrophy  is  to  be  feared,  which  is  not  the  case 
when  this  part  of  the  field  is  normal,  for  tliis  shows  that  the  power  of 
conductibility  in  the  part  of  the  retina  afiected  with  the  scotoma  is 
perfectly  retained  (Von  Graefe). 

We  cannot  form  our  prognosis  of  the  case  simply  from  the  appear- 
ances presented  by  the  optic  nerve,  for,  as  Von  Graefe  remarks,  it  is 
impossible  to  tell  from  these  alone,  whether  the  atrophy  be  progressive 
or  stationary.  In  conjunction  with  the  appearance  of  the  optic  nerve, 
we  must  therefore  be  guided  by  the  condition  of  the  field  of  vision,  and 
the  mode  in  which  the  attack  occurred.  Even  the  absence  of  atrophic 
symptoms  in  the  nerve  does  not  exclude  the  most  unfavourable  result. 
In  cases  of  amblyopia  due  to  disturbances  in  the  circulation,  or  to  alcohol, 
or  in  that  form  which  is  sometimes  met  with  in  very  nervous  females  and 
in  children,  the  jDresence  of  symptoms  of  atrophy  of  the  optic  nerve  are 
always  of  material  consequence,  as  they  greatly  cloud  the  prognosis. 

Treatment. — This  must  of  course  be  specially  directed  against  the 
primary  cause  of  the  affection  of  the  eye.  In  those  cases  of  simple 
progressive  atrophy,  in  which  we  fail  to  detect  any  appreciable  organic 
or  functional  cause,  we  must  be  extremely  upon  our  guard  not  to 
submit  the  patient  to  a  very  active  course  of  treatment,  more  especially 
of  a  lowering  or  depressing  kind.  For  great  mischief  is  thus  often 
produced,  and  the  progress  of  the  disease  hastened,  instead  of  being 
arrested  or  retarded.  The  best  treatment  for  such  cases  consists  in 
the  administration  of  tonics,  especially  the  tinctiire  of  the  muriate  of 
iron,  or  a  combination  of  steel  with  quinine  or  strychnine.  The  lactate 
or  sulphate  of  zinc  may  also  be  given  in  gradually  increasing  doses, 


AMAUROSIS.  407 

commencing  vdth  one  grain  daily,  and  augmenting  this  gradually  until 
the  patient  takes  three  or  four  grains  a-day.  The  diet  should  be 
nutritious  but  light,  and  the  effect  of  stimulants  be  closely  watched. 
The  patient's  course  of  life  should  be  carefully  regulated,  a  sufficiency 
of  sleep  be  insisted  on,  and  all  amusements  or  employment,  that  may 
prove  injurious  to  his  eyes  or  general  health,  be  strictly  foi'biddeu.  The 
use  of  tobacco  must  also  be  absolutely  given  up. 

If  there  is  any  evidence  of  the  existence  of  chronic  meningitis, 
irregularities  in  the  circulation  (more  especially  the  cerebral),  or  a 
suppression  of  customary  discharges,  such  as  the  menstrual,  or  the 
exhalations  from  the  skin,  more  particularly  the  feet,  a  derivative 
course  of  treatment  must  be  employed.  Leeches  should  be  applied 
behind  the  ears,  or  the  artificial  leech  to  the  temple,  and  a  seton  may  be 
inserted  at  the  nape  of  the  neck,  which  often  affords  great  and  speedy 
relief  to  the  severe  and  persistent  headache.  The  bichloride  of  mercury 
should  be  given  in  small  doses,  in  combination  perhaps  with  the  iodide 
and  bromide  of  potassium,  more  especially  if  any  syphiHtic  taint  is 
suspected.  The  sudden  suppression  of  the  normal  exhalations  from  the 
skin  is  not  an  unfrequent  cause  of  amblyopic  affections,  more  especially 
after  long  exposure  to  cold  and  wet.  Thus  persons  who  have  stood 
for  many  hours  in  the  water  (sportsmen,  fishermen,  etc.),  are  sometimes 
affected  with  amblyopia,  on  account  of  the  suppression  of  the  exliala- 
tions  from  the  feet.  In  such  cases  hot  stimulating  pediluvia,  together 
with  diaphoretics  and  diuretics  should  be  prescribed.  Graefe  also 
advocates  the  Roman  or  Turkish  bath,  as  specially  exciting  the  action 
of  the  skin,  which  wiU  also  prove  of  benefit  in  the  different  forms  of 
congestive  amblyopia.* 

If  the  affection  of  the  eye  is  due  to  some  sudden  fright  or  shock  to 
the  nervous  system,  tonics  should  also  be  prescribed. 

In  the  amaurosis  due  to  locomotor  ataxy,  innumerable  remedies 
have  been  tried.  Dr.  Althausf  states  that  he  has  derived  much  benefit 
in  cases  of  locomotor  ataxy  from  the  administration  of  small  doses  of 
nitrate  of  silver.     He  gives  the  silver  together  with  the  hypophosphite 

*  An  important  and  interesting  fact  in  connection  with  this  subject  has  been 
noticed  by  Dr.  Leared.  Having  found  that  persons  affected  with  fulness  and  con- 
gestion of  the  head,  were  often  mvich  benefited  by  the  Tui'kish  bath,  he  thought 
that  the  readiest  mode  of  ascertaining  the  effect  of  the  latter  upon  the  cerebral 
circulation  woidd  be  by  observing  its  influence  upon  the  blood-vessels  of  the  retina. 
Mr.  "Wordsworth  therefore  examined  Dr.  Leared's  eyes  with  the  ophthalmoscope 
just  prior  to  liis  entering  the  bath,  and  again  after  he  had  remained  in  the  hottest 
chamber  (196  F.)  for  a  quarter  of  an  hovir,  and  then  found  a  decided  and  marked 
paleness  of  the  optic  nerve,  and  a  diminution  in  the  size  of  the  retinal  vessels.  The 
same  effect  was  noticed  in  four  persons  employed  in  the  bath  (a  negro,  an  East 
Indian,  an  Englishman,  and  a  German),  under  a  temperature  of  120  E.,  who  were 
examined  at  the  same  time  by  Mr.  Wordsworth. 

t  Lectures  on  Epilepsy,  Hysteria,  and  Ataxy,  1866. 


408  AMBLYOPIC   AFFECTIOXS. 

of  soda,  and  he  never  goes  beyond  tlie  dose  of  half  a  grain  of  the  nitrate 
of  silver.  It  should  be  employed  for  from  four  to  six  weeks  consecutively, 
and  then  discontinued  for  a  fortnight  or  tlu-ee  weeks,  a  slight  aperient 
mineral  water  being  given  in  the  meanwhile.  Then  the  use  of  the 
remedy  may  be  again  commenced  and  continued  for  a  month  or  so. 
The  gums  should  be  examined  from  time  to  time,  as  the  peculiar  dusky 
discolouration  of  the  skin,  which  the  long  continued  use  of  nitrate  of 
silver  produces,  first  appears  in  the  mucous  membranes. 

Cases  of  amaurosis  have  been  recorded  in  which  it  has  been  stated 
that  great  benefit  has  been  derived  from  the  subcutaneous  injection  of 
strychnine.*  But  the  histories  of  these  cases,  more  especially  the  con- 
dition of  the  eyes,  have  not  been  given  with  sufiicient  accuracy  or 
minuteness  to  permit  of  our  forming  any  opinion  as  to  the  value  of  this 
remedy.  The  amount  to  be  injected  at  first,  is  about  one-fortieth  of  a 
grain,  to  be  gradually  increased  to  one-twentieth. 

If  central  scotomata  have  been  developed  during  protracted 
enfeebling  general  illness,  such  as  typhoid  or  scarlet  fever,  diphtheria, 
childbed,  etc.,  tonics  and  a  generous  diet,  with  stimulants,  are  the  best 
remedies  ;  and  subsequently,  when  the  sight  is  beginning  to  improve, 
much  benefit  is  often  derived  from  methodically  practising  the  sight 
(even  the  eccentric)  with  strong  convex  lenses,  as  is  done  in  cases  of 
amblyopia  from  non-use.  An  improvement  upon  the  ordinary  single 
convex  lens  is  recommended  by  Von  Graefe,  viz.,  a  combination  of  two 
bi- convex  lenses  (the  one  6  inches  the  other  4)  set  in  a  tube  or  ring  at  a 
distance  of  one  inch  from  each  other.  We  thus  gain  a  relatively  con- 
siderable magnifying  power  with  only  slight  spherical  aberration.  The 
eye  should  at  first  be  only  practised  for  a  very  short  time  (about  two  or 
three  minutes),  and  with  print  that  can  be  tolerably  easily  deciphered. 

If  there  is  any  disturbance  in  the  functions  of  the  liver  or  digestive 
organs,  mild  aperient  mineral  waters  should  be  prescribed,  such  as  the 
Pullna,  Karlsbad,  or  Kissingen  waters. 

1.— AMBLYOPIA. 

This  aflFection  is  often  due  to  passive  congestion  of  the  brain,  the  eye, 
or  other  organs,  such  as  the  liver,  uterus,  etc.,  or  to  distm-bance  of  the 
nervous  functions. 

We  must  admit  that  the  term  passive  congestion  is  very  vague,  and 
that  we  do  not  know  with  any  certainty  the  mode  in  which  the  sight 
becomes  affected,  and  whether  this  is  due  to  a  retardation  of  the  blood 
supply  and  a  consequent  insufficiency  of  its  aeration,  or  whether  it  is 
loaded  with  noxious  ingredients,   such  as  alcohol,  nicotine,  lead,  etc., 

*  Vide  Freraincau,  "  Gaz.  dcs  H6p.,"  1863  ;  Saiiiaun,  "  Deutsche  Klinik.,"  1864. 


AMBLYOPIA.  409 

which  exert  a  toxic  influence  and  thus  impair  the  functions  of  the 
nervous  system. 

For  practical  purposes  we  must,  however,  draw  a  line  of  demarca- 
tion between  the  amblyopisB  which  are  due  to  simple  irregularities  in 
the  circulation  or  nervous  functions,  and  those  which  depend  upon 
some  blood  poisoning,  if  this  term  may  be  accepted. 

The  insufficiency  of  blood  supply  which  gives  rise  to  the  ancemlc 
amblyopia  may  be  due  to  some  excessive  discharge  from  the  uterus,  to 
the  debility  consequent  uj^on  very  severe  illnesses,*  to  a  prolonged  and 
very  exhausting  confinement,  or  to  over- suckling.  Copious  haemorrhages 
(e.g.,  after  confinement)  may  likewise  produce  it.  Cases  are  also  recorded 
in  which  vomiting  of  blood  (probably  dependent  upon  an  ulcer  of  the 
stomach)  has  produced  amaurosis.*  In  these  cases,  the  loss  of  sight 
had  come  on  rapidly  (leading  to  complete  blindness  in  the  course  of  a 
few  days),  which  affected  both  eyes,  and  was  incurable.  The  ophthalmo- 
scopic appearances  were  either  negative,  or  were  those  of  anaemia  of  the 
optic  nerve  and  retina,  leading  subsequently  to  atrophy.  When  the  loss 
of  blood  is  very  considerable,  the  function  of  the  optic  nerve  is  probably 
impaired  by  the  anaemia  of  the  bi'ain  and  the  insufficient  excitation  of 
the  retina.  But  it  is  remarkable  (as  Von  Graefe  has  pointed  out)  that 
the  sight  does  not  necessarily  return  with  a  restoration  of  the  blood- 
supply  and  a  restitution  of  the  other  functions.  This  is  probably 
Giving  to  the  fact,  that  the  temporary  deficiency  in  the  blood  supply  has 
caused  permanent  changes  in  the  nutrition  of  the  ruore  delicate  nerve 
structures. 

The  amblyopia  which  is  met  with  in  diabetes  is  sometimes  due  to 
paralysis  of  the  accommodation,  or  to  retinitis,  somewhat  akin  in  its 
nature  to  that  met  wdth  in  Bright's  disease,  and  only  rarely  to  angemia. 
In  cholera  we  might  expect  that  there  would  be  great  amblyopia  on 
account  of  the  poverty  of  the  blood,  but  this  is  not  so. 

Congestive  amblyopia  may  be  due  to  over-fulness  of  the  system  and 
congestion  of  the  eye,  brain,  or  other  organs.  It  is  not  unfrequently 
met  wdth  in  cases  of  suppression  of  customary  discharges,  deficiency 
or  absence  of  the  catamenia,  and  insufficient  action  of  the  skin  or 
kidneys.  Mr.  Lawsonf  narrates  a  case  in  which  suppression  of  the 
menses  produced,  within  a  few  days,  complete  amaurosis  in  one  eye 
and  great  impairment  of  vision  in  the  other. 

Under  the  use  of  iodide  of  potassium,  and  with  the  re-appearance 
of  the  catamenia,  the  sight  was  restored. 

A  very  interesting  and  extraordinary  case  is  also  reported  by 
Mr.  Lawson,J  in  which  amaurosis  repeatedly  recurred  during  the 
period  of  gestation. 

*  O'Eeilly,  "  Lancet,"  1852 ;  VoJi  Graefe,  "  A.  f.  O.,"  Tii,  2,  143. 

t  "  Med.  Times  and  Gazette,"  1863.  t  "R-  L.  O.  H.  Eep,"  iv,  65. 


410  AMBLYOPIC   AFFECTIONS. 

The  real  nature  of  tlie  amblyopia  which  is  observed  in  certain  cases 
of  so-called  blood  poisoning  is  at  present  quite  obscure.  It  is  generally- 
supposed  to  be  due  to  some  disturbance  in  the  circulation,  producing 
what  is  termed  passive  congestion  of  the  brain.  But  this  explanation  is 
indefinite  and  unsatisfactory,  for,  as  Von  Grraefe  says,*  "  Whether  there 
is  a  real  inundation  of  the  nervous  centre,  with  venous  blood, — whether 
the  current  and  change  of  the  blood  is  too  slow  only, — or  whether  the 
visual  function  is  affected  from  the  blood  being  overloaded  with  alcoholic 
and  narcotic  substances,  are  so  many  questions  suggested  by  the  term 
'  passive  cerebral  congestion.'  This  term,  therefore,  only  serves  to 
designate  a  condition  where,  failing  all  evidence  of  active  congestion, 
the  functional,  or,  as  the  case  may  be,  also  the  nutritional  excitation  of 
the  cerebral  centre  of  the  optic  nerve  is  interfered  with  by  circulatory 
influences  of  the  aforesaid  order." 

This  toxic  influence  may  be  especially  produced  by  alcohol,  tobacco, 
lead,  and  quinine. 

The  amblyopia  met  with  in  drunkards  (amblyopia  potatorum) 
generally  commences  with  the  appearance  of  a  mist  or  cloud  before  the 
eyes,  which  more  or  less  surrounds  and  shrouds  the  object,  rendering 
it  hazy  and  indistinct.  In  some  cases,  the  impairment  of  vision  becomes 
very  considerable,  so  that  only  the  largest  print  can  be  deciphered,  but 
if  progressive  atrophy  of  the  optic  nerve  sets  in,  the  sight  may  be  com- 
pletely lost.  The  visual  field  may  remain  normal  or  become  more  or 
less  contracted.  The  afiection  may  exist  for  a  very  long  time  without 
causing  any  organic  changes  in  the  optic  nerve  or  retina,  excepting  those 
of  hyperaemia,  and  a  certain  loss  of  transparency  in  the  disc.  In  other 
cases,  if  the  disease  progresses  or  the  cause  persists,  atrophy  of  the  optic 
nerve  supervenes,  and  this  always  materially  clouds  the  prognosis ;  for 
although  we  may,  even  in  such  cases,  sometimes  succeed  in  securing  a 
great  improvement  of  sight  and  an  arrest  of  the  atrophic  degeneration, 
yet  the  vision  is  but  seldom  restored  ad  integrum. 

In  many  of  these  cases,  we  cannot  detect  any  abnormal  appearances 
with  the  ophthalmoscope,  and  must  therefore  regard  the  impairment  of 
sio-ht  as  due  to  a  functional,  and  not  to  an  organic,  lesion.  In  other  cases 
there  is  some  hypersemia  of  the  retina  and  optic  nerve,  with,  perhaps, 
a  certain  degree  of  passive  congestion,  together  with  a  diminution 
in  the  transparency  of  the  disc,  and  subsequently  symptoms  of  atrophy 
of  the  optic  nerve  may  make  their  appearance.  But  I  must  here  again 
warn  the  reader  against  too  readily  assuming  the  existence  of  hypera^mia 
and  congestion  of  the  optic  nerve  and  retina,  simply  because  the  disc 
may  seem  to  him  to  be  shghtly  too  red,  or  the  veins  somewhat  large. 
It  has  been  already  stated  that  the  appearances  of  the  optic  disc  and  of 
the  retinal  circulation  vary  very  greatly  withui  a  perfectly  physiological 
*  "  Oplith.  Eeview,"  ii,  p.  340. 


AMELYOPIA.  411 

standard,  and  that  it  often  requires  an  experienced  and  careful  observer 
to  determine  whether  or  not  some  marked  peculiarity  in  the  appearance 
of  these  structures  is  physiological  or  pathological.  In  judging  of  these 
conditions,  we  must  take  into  especial  consideration  the  age,  the  habits, 
the  complexion,  etc.,  of  the  patient. 

The  prognosis  will  depend  chiefly  upon  the  condition  of  the  optic 
nerve,  the  length  of  time  which  the  disease  has  existed,  and  the  fact 
whether  or  not  the  patient  is  willing  entirely  to  give  up  any  habits 
which  may  have  caused  it. 

The  effect  of  tobacco  in  producing  amblyopia  and  amaurosis  was 
originally  pointed  out  by  Mackenzie ;  more  lately  Critchett,  Words- 
worth, Hutchinson,  and  Sichel  have,  amongst  others,  paid  much  atten- 
tion to  this  subject,  and  believe  that  it  gives  rise  to  a  peculiar  and 
distinctive  form  of  loss  of  sight,  which  they  have  therefore  termed 
"  tobacco  amaurosis."  It  is  supposed  to  produce  a  peculiar  form  of 
atrophy  of  the  optic  nerve,  the  symptoms  of  which  are  so  special  as  to 
be  considered  characteristic  of  tobacco  amaurosis  (vide  article  on  Atrophy 
of  the  Optic  Nerve,  p.  387).  One  argument  which  has  been  brought 
forward  to  lend  special  weight  to  the  theory  that  tobacco  may  produce 
amaui'osis  is,  that  simple  progressive  atrophy  of  the  optic  nerve  occurs 
far  more  frequently  amongst  men  than  women.  Whilst  readily  con- 
ceding thisj  I  must  also  call  attention  to  the  fact  that  the  causes 
which  may  produce  amaurosis  obtain  far  more  amongst  men  than  women. 
Thus  the  former  are,  as  a  rule,  exposed  to  far  greater  corporeal  and 
mental  labour,  to  greater  vicissitudes,  and  to  a  greater  indulgence  in 
free  living  of  every  kind.  Moreover,  in  all  probability,  the  amaurosis  is 
far  more  due  to  a  combination  of  such  deleterious  influences  than  to  the 
prevalence  of  one  special  one,  e.g.,  tobacco.  At  least,  in  by  far  the 
greater  number  of  cases  of  amaurosis  which  I  have  met  with  in  heavy 
smokers,  the  patients  readily  admitted  their  free  indulgence  in  other 
excesses.  I  fully  admit  the  fact,  that  the  excessive  use  of  tobacco 
(but  most  frequently  together  with  other  causes)  may  produce  con- 
siderable impairment  of  vision,  and  finally,  if  the  habits  of  the  patient 
be  not  entirely  changed,  and  the  use  of  tobacco,  stimulants,  etc.,  given 
up,  even  atrophy  of  the  optic  nerves.  But  I  cannot,  from  my  own 
experience,  accede  to  the  doctrine  that  there  is  anything  peculiar  in  the 
fonn  of  atrophy  of  the  optic  nerve,  which  would  at  once  enable  one  to 
diagnose  the  nature  of  the  disease,  as  depending  upon  excessive  smoking. 
For  the  three  peculiarities  particularly  insisted  on,  viz.,  the  premonitory 
hyperaemia  of  the  disc,  the  blanching  of  the  latter  first  at  the  outer  side, 
and  the  diminution  in  the  size  or  even  disappearance  of  the  nutritive 
vessels  of  the  optic  nerve,  whilst  the  retinal  vessels  for  a  very  long  time 
retain  their  normal  caHbre,  are  met  with  in  other  forms  of  atrophy  of 
the  optic  nerve,   and  are  therefore  not  at  all  distinctive  of  tobacco 


412  AMBLYOPIC   AFFECTIONS. 

amaurosis.  Indeed  it  is  impossible  to  understand  why  tobacco  alone 
should  produce  these  peculiar  changes.  I  believe  that  in  the  commence- 
ment of  the  amblyopia  of  smokers  and  drunkards  the  disturbance  of 
sight  is  at  first  only  fanctional,  the  retina  being,  so  to  say,  "  blunted," 
and  its  sensibility  impaired,  so  that  it  does  not  re-act  with  normal  acute- 
ness.  This  impairment  of  its  function  is  probably  chiefly  due  to  some 
irregularity  in  the  circulation  in  the  nervous  centres,  although  it  is  also 
probable  that  in  many  cases  (especially  of  tobacco  amaurosis)  there  is 
some  depressing  influence  exerted  directly  upon  the  nervous  system. 
The  truth  of  this  hypothesis  is  proved  by  the  fact  that  at  first  the 
optic  nerve  and  retina  are  quite  healthy  or  only  somewhat  hyperaemic, 
and  that  great  and  rapid  improvement  takes  place  when  the  patient 
relinquishes  smoking,  drinking,  etc.,  and  is  submitted  to  a  tonic 
course  of  treatment,  together,  perhaps  with  local  depletion.  But  if  the 
cause  persists,  if  the  patient  continues  his  indulgence  in  smoking, 
drinking,  etc.,  combined,  perhaps,  with  severe  mental  or  corporeal 
exertion,  then  the  disease  does  not  remain  confined  to  mere  functional 
derangement,  but  generally  passes  over  into  an  organic  lesion.  The 
optic  disc  begins  to  show  symptoms  of  atrophic  degeneration,  and  the 
latter  may  gradually  but  steadily  advance  until  the  sight  is  greatly 
impaired  or  even  quite  lost  (Graefe). 

The  absorption  of  lead  into  the  system  will  produce  amaurosis.  I 
have  only  met  with  one  case  in  which  the  loss  of  sight  could  be  dis- 
tinctly traced  to  lead-poisoning.  This  was  in  a  young  woman,  who  a 
few  months  ago  came  under  my  care  at  Moorfields.  She  had  been  a 
worker  in  lead,  and  had  sufiered  from  severe  lead  poisoning.  She  was 
completely  blind,  and  both  optic  nerves  showed  marked  symptoms  of 
atrophy  consecutive  upon  optic  neuritis.  Mr.  Hutchinson  has  men- 
tioned to  me  that  he  has  seen  similar  instances,  in.  which  lead- poisoning 
had  given  rise  to  optic  neuritis,  followed  by  atrophy  of  the  optic  nerves. 
Very  generally,  however,  the  only  symptoms  revealed  by  the  ophthal- 
moscope are  congestion  and  hypersemia  of  the  optic  nerve  and  retina, 
the  veins  especially  being  somewhat  dilated  and  tortuous.  The  sight 
and  field  of  vision  are  even  in  such  cases  often  considerably  impaired. 
It  must  be  mentioned  that  albuminuria  is  sometimes  met  with  in  lead 
poisoning,  and  that  consequently  albuminuric  retinitis  may  occur 
(Ollivier,  Desmarres). 

Quinine  in  large  doses  has  been  in  rare  instances  observed  to  pro- 
duce amaurosis,  probably  by  causing  great  congestion  of  the  cerebral 
circulation,  as  much  benefit  was  derived  from  the  use  of  the  artificial         . 
leech,  "a  V 

Urcemlc  amhlyopia.  In  the  article  upon  retinitis  albuminurica,  it 
was  mentioned  that  very  sudden  and  complete  blindness  sometimes 
occurs  in  Bright's  disease,  and  is  due  to  ureemic  blood  poisoning.     The 


AMBLYOPIA.  413 

sight  may  be  lost  within  a  very  few  hours,  together  with  the  appearance 
of  symptoms  of  urEemic  blood  poisoning,  such  as  great  pain  in  the  head, 
epileptoid  fits,  etc.*  Then,  on  the  subsidence  of  these  symptoms,  the 
sight  is  also  restored.  This  impairment  of  vision  must  be  carefully 
distinguished  from  that  dependent  upon  retinitis  albumintirica. 

Amblyopia  is  sometimes  due  to  reflex  irritation  originating  in  one 
of  the  branches  of  the  fifth  nerve,  or  in  other  parts  of  the  nervous 
system.  Thus  severe  and  prolonged  dental  neuralgia  may  produce  im- 
pau'ment  of  vision,  which  mostly  disappears  with  the  removal  of  the 
carious  teeth.  The  ophthalmoscopic  examination  generally  only  aifords 
negative  results. t  In  a  case  of  abscess  of  the  antrum  from  a  carious 
tooth,  narrated  by  Dr.  James  Salter,  the  eye  was  considerably  pro- 
truded and  bUnd — the  ophthalmoscope  revealing  extreme  anemia  of 
the  optic  nerve  (atrophy?).  The  sight  was  not  improved  by  the 
removal  of  the  tooth.  In  a  case  of  herpes  frontaUs,  accompanied  by 
great  pain,  recorded  by  Mr.  Bowman,  the  optic  nerve  was  atrophied.  J 

When  one  eye  is  excluded  for  any  length  of  time  from  binocular 
vision,  its  sight  generally  begins  to  fail  from  non-use  of  the  eye.  This 
condition  is  termed  amblyopia  ex  anopsia,  and  is  especially  met  with  in 
cases  in  which,  on  account  of  the  presence  of  some  opacity  of  the 
cornea  or  lens,  or  of  strabismus  accompanied  with  diplopia,  the 
acuteness  of  vision  of  one  eye  is  considerably  greater  than  that  of  the 
other,  so  that  the  difference  in  the  distinctness  of  the  two  retinal 
images  proves  very  confusing  to  the  patient,  and,  in  order  to  remedy 
this,  he  unconsciously  suppresses  the  recognition  of  the  less  distinct 
image.  This  active  suppression  of  the  one  image  by  the  mind  must  be 
distinguished  from  its  passive  suppression  caused  by  a  dense  opacity 
of  the  cornea  or  lens,  the  presence  of  which  prevents  any  image  being 
formed  upon  the  retina.  The  active  suppression  of  the  retinal  image 
is  far  more  injurious  to  the  sight  than  the  passive.  But  both  are 
especially  so  in  children,  for  in  them  we  often  find  that  after  a  stra- 
bismus has  existed  for  some  time  (six  or  twelve  months),  the  sight  of 
the  eye  may  be  so  much  impaired  that  only  large  print  can  be  deci- 
phered with  this  eye,  and  yet  it  appears  in  all  other  respects  perfectly 
normal.  Moreover,  if  the  squint  is  operated  upon,  and  the  eye  then 
practised  separately  with  strong  convex  glasses,  the  sight  may  be 
rapidly  restored,  if  the  impairment  of  vision  had  not  reached  too  high 
a  degree.     This  proves  that  the  defect  of  sight  is  not  congenital,  as  has 

*  A  case  of  this  ursemic  amaurosis  followed  afterwards  by  retinitis  albuminm-ica 
is  recorded  by  Graefe,  "  A.  f.  O.,"  vi,  2,  277. 

t  Cases  of  amblyopia,  accompauyiug  dental  neuralgia,  liave  been  recorded  by 
Mr.  Hutchinson,  "  E.  L.  O.  H.  Rep.,"  vol.  iv,  381 ;  also  by  Wccker,  "  Ann. 
d'Oculist,"  1866. 

X  "R.  L.  O.  H.  Eep.,"  v. 


414  AMBLYOPIC   AFFECTIONS. 

been  sometimes  supposed,  but  is  due  to  tlie  exclusion  of  the  eye  from 
binocular  vision  and  consequent  disuse  of  the  retina.  Besides,  if  the 
squint  is  alternating,  so  that  each  eye  is  used  in  turn,  the  sight  of  both 
remains  perfectly  good.  The  rare  cases  of  non-alternating  strabismus, 
in  which  the  sight  of  the  squinting  eye  still  retains  its  normal  acute- 
ness,  are  probably  due  to  their  not  enjoying  binocular  vision,  in 
consequence  of  which  there  is  no  diplopia,  and  of  course  no  active 
suppression  of  the  double  image.  This  subject,  however,  is  more  fully 
treated  of  in  the  article  upon  Strabismus.  In  children,  even  the  passive 
exclusion  of  the  eye  (e.g.,  from  cataract)  leads  to  amblyopia  far  sooner 
than  in  adults,  in  whom  complete  cataract  may  exist  for  very  many 
years  (Von  Graefe  has  recorded  such  a  case  in  which  a  cataract  had 
existed  for  sixty  years),  and  yet,  when  it  has  been  successfully  removed 
by  operation,  the  patient  can  see  perfectly.  In  cliildren,  however,  this 
is  not  the  case,  and  the  sensibility  of  the  retina  is  apt  permanently  to 
suffer ;  hence  the  rule,  that  in  children  cataract  as  well  as  strabismus 
should  be  operated  upon  soon  after  its  appearance. 

Sudden  and  severe  blows  upon  the  eye  may  produce  complete  and 
instantaneous  blindness,  apparently  from  paralysis  of  the  retina  {com- 
motio retince).  The  same  has  been  observed  after  a  stroke  of  lightning.* 
The  ophthalmoscope  generally  reveals  no  symptoms  at  all  commensu- 
rate with  the  degree  of  blindness ;  perhaps  there  is  only  some  hypergemia 
of  the  retina  and  optic  nerve,  or  a  few  scattered  blood  extravasations.  In 
other  cases  nothing  abnormal  is  observed,  and  the  loss  of  sight  is  probably 
due  to  some  disturbance  or  derangement  in  the  retinal  elements,  wliich 
are,  however,  invisible  vsdth  the  ophthalmoscope.  But  Wecker  mentions 
a  case  in  which  atrophy  of  the  optic  nerve  subsequently  supervened.* 
The  sight  in  these  cases  of  paralysis  of  the  retina,  often  becomes  per- 
fectly restored,  even  although  all  perception  of  light  may  at  first  have 
been  lost. 

The  treatment  of  the  different  forms  of  amblyopia  must  vary  with 
the  cause  of  the  affection.  Thus,  in  cases  where  the  latter  is  evidently 
due  to  great  debility,  consequent,  perhaps,  upon  severe  illness,  hyper- 
lactation,  etc.,  tonics,  a  generous  diet,  plenty  of  exercise  in  the  open 
air,  sea  bathing,  etc.,  must  constitute  the  chief  remedial  agents. 
Whereas,  in  the  congestive  amblyopia  great  attention  must  be  paid  to 
the  free  action  of  the  various  eliminative  organs,  more  especially  the 
liver,  skin,  and  kidneys.  For  this  purpose  saline  mineral  waters, 
diuretics,  hot  stimulating  pediluvia,  and  the  hot  air  or  Turkish  bath, 
will  prove  of  special  advantage.  In  Germany  the  prolonged  use  of  the 
decoction  of  Zittman  is  a  favourite  remedy,  but  this  mode  of  treatment 
is  accompanied  by  so  much  inconvenience,  that  but  few  English  patients 
will  submit  to  it.  In  the  congestive  amblyopia,  I  have  often  derived 
*  Vide  also  Sainisch,  "  Kl.  Monatabl.,"  p.  22,  1864. 


AMBLYOPIA.  415 

the  greatest  benejQt  from  the  rejjeated  use  of  the  artificial  leech.  In 
some  cases,  even  its  first  application  was  followed  by  the  most  marked 
and  surprising  improvement  in  the  sight.  Hence,  I  would  particularly 
insist  upon  the  necessity  of  always  giving  the  artificial  leech  a  trial  in 
cases  of  amblyopia  or  amaurosis,  in  which  there  is  evidence  or  suspicion 
of  congestion,  or  of  irregTilarities  in  the  circulation ;  for  this  remedy  is 
at  present  far  too  much  neglected  in  England.  The  blood  should  be 
drawn  rapidly,  so  that  the  glass  cylinder  becomes  filled  in  three  or 
fom-  minutes.  One  or  two  cylinders  full  from  each  temple  (if  both 
eyes  ai-e  aftected)  will  generally  suffice.  The  operation  may  be  repeated 
at  intervals  of  five  or  six  days,  but  if  there  is  no  improvement  of  sight 
after  it  has  been  performed  two  or  three  times,  it  should  not  be  repeated. 
After  each  application  of  the  artificial  leech,  the  patient  should  be  kept 
in  a  darkened  room  for  about  24  hours,  as  the  operation  is  generally 
followed  by  a  good  deal  of  reaction  in  the  intra-ocular  circulation. 

We  must  also  insist  upon  the  patient  leading  a  most  regular  Kfe, 
and  abstaining  from  excesses  of  every  kind,  and  in  the  amblyopia 
potatorum  the  allowance  of  spirituous  Hquors  must  be  cut  down  to  a 
minimum.  If  the  nervous  system  is  enfeebled,  tonics  must  be  admini- 
stered in  considerable  doses,  more  especially  steel,  either  alone  or  in 
combination  with  quinine  or  strychnine.  The  Tinct.  Ferri  Muriat.  (from 
gtts.  XV  to  5ss.  or  more,  two  or  three  times  daily)  often  proves  of  much 
benefit. 

In  order  to  alleviate  the  extreme  restlessness  and  nervous  irritability 
of  such  patients,  digitalis  or  hyoscyamus  should  be  prescribed,  and 
morphia  should  be  administered  at  night  to  relieve  the  great  and  very 
trying  sleeplessness,  or  the  subcutaneous  injection  of  morphia  may  be 
employed  'ndth  advantage. 

In  tobacco  amaurosis  the  greatest  stress  must  be  laid  upon  the  abso- 
lute 'imiXi^iiUy  ot  tne  patient's  entirely  giving  up  the  use  of  tobacco. 
Only  in  this  way  can  we  hope  to  cure  or  arrest  the  disease.  Moreover, 
it  is  generally  more  easy  for  a  great  smoker  to  break  liimself  at  once 
and  altogether  of  the  habit,  than  to  limit  himself  to  one  or  two  cigars 
or  pipes  a  day,  for  then  the  temptation  of  exceeding  this  amount  is  con- 
stantly presented  to  him.  At  the  same  time  tonics  (particularly  the 
tincture  of  steel,  alone  or  in  combination  with  strychnine)  should  be 
prescribed.  By  pursuing  this  course  of  treatment,  we  may  generally 
succeed  in  rapidly  curing  the  amblyopia  if  it  be  still  only  functional,  or 
of  an-esting  it  and  greatly  improving  the  sight  if  the  optic  nerve  is  only 
slightly  atrophied. 

In  the  impairment  of  ^dsion  from  lead  poisoning  many  remedies 
have  been  recommended,  of  which  the  inost  reliable  is  probably  opium. 
This  has  been  found  to  shorten  the  course  of  the  constitutional  disease, 
to   diminish    the    frequency   of   paralytic   afluctions,    and    to    prevent 


416  AMBLYOPIC   AFFECTIONS. 

relapses.  The  subciitaneoiis  injection  of  morphia  has  been  employed 
with  much  benefit  in  amblyopia  saturnina  by  Dr.  Haase.*  As  a  rule, 
such  cases  afford  a  favourable  prognosis  if  symptoms  of  optic  neuritis 
or  atrophy  of  the  optic  nerve  have  not  supervened.  The  patient  must, 
however,  be  warned  not  again  to  expose  himself  to  the  risk  of  renewed 
lead-poisoning,  otherwise  a  relapse  may  occur. 

The  amblyopia  due  to  disuse  of  the  eye  is  best  treated  by  methodi- 
cally exercising  the  sight  in  reading,  etc.,  with  the  aid  of  a  strong  con- 
vex lens,  or  still  better,  Von  Graefe's  combination  of  two  lenses  set  in  a 
small  tube.  The  eye  should  be  practised  frequently  during  the  day, 
but  only  for  the  space  of  two  or  three  minutes  at  a  time. 

In  the  loss  of  sight,  dependent  upon  paralysis  (commotio)  of  the 
retina,  antiphlogistics  (more  especially  the  artificial  leech,  blisters,  etc.) 
should  be  at  first  appHed.  Subsequently  electricity  should  be  tried, 
and  strychnine  (perhaps  in  combination  with  tonics)  be  administered. 
Wecker  recommends  the  use  of  subcutaneous  injections  of  strychnine. 


2.— HEMERALOPIA. 

This  disease  is  especially  characterised  by  the  fact  that  although 
the  patient  may  be  able  to  see  very  well  diu-ing  the  bright  daylight,  his 
sight  rapidly  deteriorates  towards  dusk,  and  still  more  so  at  nightfall ; 
hence  the  term  night  bhndness.  When  the  illumination  is  insufficient, 
a  more  or  less  dense  grey,  or  purple  cloud  surrounds  and  renders  all 
objects  indistinct  and  hazy,  and  also  impairs  the  power  of  distinguishing 
colours.  Thus,  according  to  Forsterjf  certain  colours,  especially  white, 
yellow,  and  green,  can  be  more  readily  distinguished  than  blue,  violet, 
or  red.  The  pupil  is  wide  and  sluggish  on  the  admission  of  light,  but 
reacts  normally  on  irritation  of  the  branches  of  the  fifth.,  e.g.,  on  the 
instillation  of  tincture  of  opium.  In  retinitis  pigmentosa,  the  pupil  is, 
on  the  contrary,  contracted.  In  severe  cases  the  impairment  of  sight 
may  be  so  great,  that  even  large  objects  cannot  be  distinguished  when 
the  light  is  much  diminished.  It  is,  however,  an  error  to  suppose  that 
the  dimness  of  sight  is  due  to  the  setting  of  the  sun,  and  that  it  is  thus 
linked  to  a  certain  time  of  the  day.  Identically  the  same  symptoms 
appear  if  the  illumination  is  artificially  diminished,  by  placing  the  patient 
in  a  darkened  room.  This  fact  was  most  satisfactorily  proved  by 
Forster,  with  his  ingenious  optometer.  The  dimness  of  vision  is  only 
due  to  an  impairment  of  the  sensibility  (torpor)  of  the  retina,  so  that 
the  patient  requires  the  full  stimulus  of  bright  daylight,  or  artificial 
light,  in  order  to  see  distinctly.     This  impairment  of  the  sensibiKty  of 

*  "  Klin.  Monatsbl.,"  1867,  225. 

t  "  Ubor  Hcmeralopie,"  Breslau,  1857. 


HEMERALOPIA.  417 

the  retina  may  cithei*  be  due  to  an  insufficiency  of  blood  supply,  to  tlie 
impoverished  condition  of  the  blood,  or  to  the  nerve  elements  of  the 
retina  having  been  over-stimulated  by  prolonged  exposure  to  extremely 
bright  light.  Very  frequently,  the  hemeralopia  is  a  result  of  a  com- 
bination of  these  causes. 

It  appears  however,  to  be  true  that  in  the  early  morning,  after  a 
sound  and  refreshing  sleep,  the  sensibility  of  the  retina  is  greater  than 
at  a  subsequent  period  of  the  day,  so  that  the  patient  is  then  able  to 
see  even  by  a  somewhat  diminish.ed  illumination. 

It  is  of  great  consequence  to  distinguish  between  the  simple  heme- 
ralopia, and  that  condition  of  night  blindness  Avhicb  accompanies 
retinitis  pigmentosa.  The  former  is  simply  functional  and  curable,  the 
latter  depends  upon  organic  changes  in  the  retina,  and  at  a  later  period 
in  the  optic  nerve,  and  is  incurable.  Inattention  to,  or  ignorance  of  these 
facts  has  led  to  gi"eat  confusion  in  the  writings  of  some  authors. 

Hemeralopia  may  be  caused  by  prolonged  exposure  to  extremely 
bright  light,  such  as  the  rays  of  the  sun  in  tropical  climates,  or  the 
glare  of  a  vast  expanse  of  brightly  glistening  snow.  The  ill  effects  of 
such  exposure  make  themselves  especially  felt,  if  the  individual  is  in  a 
condition  of  great  debility  or  exhaustion,  as  after  severe  illness,  or  long 
deprivation  of  food.  Thus,  we  not  unfrequently  find  hemeralopia 
existing  amongst  sailors  returning  from  the  tropics,  who  have  been 
kept  for  a  length  of  time  without  sufficient  food,  and  have,  perhaps, 
been  suifering  from  scurvy.  I  have  several  times  had  four  or  five  sailors 
from  one  vessel  under  my  care  at  Moorfields,  for  hemeralopia.  Then- 
story  was  always  the  same.  They  had  just  landed  from  their  vessel, 
after  a  long  exposure  to  a  tropical  sun  and  a  scanty  allowance  of  food, 
and  they  had  generally  been  sufifering  from  great  debility,  or  from 
scurvy.  The  hemeralopia  had  diminished  somewhat  on  theu"  reaching 
a  more  temperate  zone,  and  rapidly  disappeared  on  their  arrival  in 
England,  under  the  administration  of  tonics  and  the  enjoyment  of  a 
generous  diet.  In  none  of  these  cases  was  I  able  to  discover  anything 
peculiar  with  the  ophthalmoscope,  the  retinal  veins  were,  perhaps,  slightly 
dilated,  but  I  could  not  trace  any  diminution  in  the  calibre  of  the 
arteries.  Indeed,  in  almost  all  cases  of  this  form  of  hemeralopia,  the 
ophthalmoscopic  examination  yields  a  negative  result.  In  several  of 
these  patients  there  were  distinctly  noticed  those  peculiar,  silvery  grey, 
scaly  patches  of  thickened  epithehum  at  the  outer  portion  of  the  ocular 
conjunctiva  near  the  cornea,  to  which  particular  attention  has  been 
called  by  Bitot.*  He  considers  these  patches  pathognomonic  of  heme- 
ralopia, and  states  that  they  disappear  consentaneously  with  the  dis- 
appearance of  the  night  blindness.  I  have,  however,  found  them  absent 
in  several  cases  of  hemeralopia,  and  they  are  evidently  quite  uucon- 

*  "  Gazette  Hepdom,"  1863. 

2  E 


418  AMBLYOPIC   AFFECTIONS. 

nected  with  this  disease,  and  only  diie  to  a  thickening  and  desiccation  of 
the  conjunctival  epithelium  from  exposure  to  intense  heat,  which  sets  up 
a  state  of  chronic  congestion  or  inflammation  of  the  conjunctiva.  The 
appearance  of  these  patches  at  the  outer  part  of  the  cornea,  is  due  to  this 
portion  of  the  ocular  conjunctiva  being  most  exposed,  on  account  of  the 
wideness  of  the  palpebral  aperture  at  this  point. 

Hemeralopia  has  also  been  observed  to  break  out  epidemically  in 
gaols,  camps,  etc.  I  need  hardly  point  out  that  in  such  cases,  a  careful 
examination  should  always  be  instituted,  in  order  to  guard  against 
"malingering."  According  to  Alfred  Graefe,  the  accommodative  power 
of  the  eye  is  often  somewhat  impaired,  there  being  also  a  certain  degree 
of  insufi&ciency  of  the  internal  recti  muscles. 

The  treatment  must  be  chiefly  directed  to  strengthening  the  general 
health  by  tonics  and  a  generous  diet.  Amongst  the  former,  quinine, 
steel,  and  cod-liver  oil  are  the  best ;  indeed  cod-liver  oil  is  considered 
by  Desponts  a-s  a  specific  for  hemeralopia.  At  the  same  time  the  patient 
naust  be  carefully  guarded  against  bright  light.  His  room  should  be 
darkened,  and  he  should  only  be  allowed  to  go  out  when  there  is  no 
sun,  and  even  then  wear  dark  eye  protectors.  If  the  attack  of  heme- 
ralopia is  severe,  it  may  be  even  necessary  to  insist  upon  keeping  him 
in  perfect  darkness  for  several  days,  and  he  should  then  be  gradually 
accustomed  to  a  greater  and  greater  amount  of  light.  Blisters  and 
local  depletion  have  been  strongly  recommended  by  some  authors,  but 
they  are  generally  contra-indicated  by  the  debility  and  feeble  condition 
of  the  patient.  But  if  there  are  marked  symptoms  of  congestion  and 
hyperfBmia  of  the  retina  and  optic  nerve,  the  effect  of  the  artificial 
leech  should  be  tried. 

In  snow  blindness  the  impairment  of  vision  is  also  chiefly  due  to  a 
diminution  of  the  sensibility  of  the  retina  from  the  great  and  prolonged 
glare,  but  it  may  likewise  perhaps  be  due  to  the  effect  of  the  gTcat  rare- 
faction of  the  atmosphere  in  high  mountain  ranges,  which  may  produce 
not  only  inflammation  of  the  conjunctiva  with  extravasations  of  blood 
into  its  tissue,  but  also  pei'haps  liEemorrhagic  effusions  into  the  choroid 
and  retina. 

Closely  allied  to  the  kbove  form  of  amblyopia,  is  the  anfesthesia  of 
the  retina  which  occurs  ia  consequence  of  prolonged  exposure  to 
extremely  bright  light  (ueberblendung  der  retina).  Instances  of  this 
kind,  are  met  with  amongst  persons  who  have  been  long  exposed  to 
strong  sunlight,  or  have  greatly  tried  their  eyes  by  excessive  microsco- 
pising,  etc.,  more  especially  by  artificial  light.  They  are  often  seized 
with  a  sudden  dimness  of  sight,  and  notice  (more  especially  if  the  illu- 
mination is  but  moderate)  a  more  or  less  dense  dark  cloud  or  disc, 
which  appears  suspended  before  their  eyes,  and  veils  the  central  portion 
of  an  object  or  of  the  field   of  vision,  leaving  the  periphery,  perhaps. 


COLOUR  BLINDNESS.  419 

quite  clear.  The  density  and  extent  of  tlie  cloud,  and  the  consequent 
degree  of  amblyopia,  as  also  its  duration,  are  subject  to  considerable 
variation.  Thus  the  cloud  may  only  be  observed  for  a  few  minutes 
after  the  exposure,  or  it  may  last  for  days  and  weeks,  or  even  longer. 
The  treatment  should  principally  consist  in  guarding  the  patient  against 
all  use  of  the  eyes  and  exposui-e  to  bright  light.  Indeed,  if  the  case  is 
severe,  it  may  be  necessary  to  insist  upon  his  being  kept  in  the  dark  for 
some  length  of  time.  The  artificial  leech  is  also  often  of  much  benefit. 
Cod-liver  oil  and  steel  should  be  prescribed  internally. 

3.— COLOUR  BLINDNESS  (DALTONISM). 

By  this  term  is  meant  the  inabiHty  which  many  persons  have  of 
distinguishing  between  certain  colours.  The  most  frequent  form  of 
colour  blindness  is  that,  in  which  red  and  the  colours  in  which  it  forms 
an  ingredient,  as  well  as  its  accidental  colour,  green,  are  more  or  less 
indistinguishable.  Thus  red  either  appears  to  be  simply  a  dark  colour, 
or  the  finer  shades  of  red  cannot  be  at  all  appreciated,  and  the  differ- 
ence between  purple,  orange,  and  brown  is  only  distinguished  with 
difficulty,  whereas  the  difference  between  yellow  and  blue  is  readily 
recognised.  Violet  is  also  distinguished,  but  is  often  mistaken  for  blue. 
In  rarer  instances,  green  is  the  colour  which  cannot  be  recognised.  The 
rarest  cases  of  all  are  those  in  which  the  colour  blindness  is  complete, 
the  individual  only  distinguishing  two  colours,  white  and  black. 

It  is  generally  held,  that  the  inability  to  distinguish  a  certain 
colour  {e.g.,  red)  is  due  to  an  insensibility  of  those  nerve  fibres  of  the 
retina  which  are  sensitive  to  red.  This  view  has,  however,  been  lately 
strongly  opposed  by  Max.  Schultze,*  who  considers  that  in  such  cases 
it  probably  depends  upon  an  excessive  development  of  the  yellow  pig- 
ment in  the  region  of  the  macula  lutea,  which  has  the  effect  of  dim.inish- 
ing  the  intensity  of  the  red  rays  of  light.f 

Colour  blindness  has  been,  as  a  rule,  supposed  to  be  congenital,  and 
even  hereditary,  but  the  interesting  fact  has  been  observed  by  Benedict, 
Schelske,  etc.,  that  colour  blindness  may  show  itself  in  atrophy  of  the 
optic  nerve,  and  according  to  Galezowski,J  also  in  other  diseases. 

In  a  practical  point  of  view  the  existence  of  colour  blindness  may 
often  be  of  great  importance,  for  instance  in  the  case  of  railway  guards, 
signal  men,  etc.,  who  have  to  distinguish  between  lamps  of  different 
colours. 

*  Vide  Max  Schultze,  "  Ueber  den  gelben  Fleck,  etc.,"  1866 ;  also  liis  work, 
"  Zur  Anatomic  und  Physiologic  der  Ketiua,"  1866. 

t  In  connexion  -witli  this  subject,  it  is  of  interest  that  during  Santonin  intoxi- 
cation  everything  acquires   a  yellow  or  greenish-yellow  tint,  but  A'iolct  and  red 
become  indistinct.     Vide  articles  upon  this  subject  by  Rose,  "  A.  f.  O.,"  vii,  2,  72 ; 
also  Uiifncr,  ib.,  xiii,  2. 
t  Chromatoscopie  Retinienne,  1868. 

2  E  2 


420  AMBLYOPIC   AFFECTIONS. 

4.— SIMULATION  OF  AMAUROSIS. 

We  occasionally  meet  with  cases  of  simulated  blindness,  more 
especially  amongst  nervous,  hysterical  females,  or  persons  who  wish  to 
shirk  their  duties,  as  soldiers,  prisoners,  etc.  In  sharp  and  clever  indi- 
viduals it  is  sometimes  very  difficult  to  convict  them  of  deceit. 
Absolute  blindness  of  both  eyes  is  but  seldom  simulated,  except,  per- 
haps, in  those  cases,  in  which  so  considerable  a  degree  of  amblyopia 
really  exists,  that  the  patient  is  unable  to  gain  his  livelihood,  and  there- 
fore pretends  to  be  absolutely  blind,  in  order  to  excite  the  commisera- 
tion and  assistance  of  the  charitable.  In  such  cases,  the  behaviour  of 
the  pupil  under  the  stimulus  of  light,  is  the  best  guide.  For  if  a  patient 
declares  that  he  is  so  blind  that  he  cannot  distinguish  between  light 
and  dark,  and  the  pupils  yet  contract  under  the  stimulus  of  light,  we 
may  with  safety  insist  upon  its  being  a  case  of  simulation.  Such 
patients,  however,  sometimes  dilate  the  pupils  artificially  with  atropine, 
and  this  may  be  suspected  if  they  are  dilated  ad  maximum,  for  in  the 
mydriasis  due  to  amaurosis  (except  the  branches  of  the  fifth  nerve 
supplying  the  dilator  pupillae  are  irritated),  the  pupil  is  but  moderately 
dilated.  If  the  action  of  atropine  is  suspected,  but  a  conviction  appears 
impossible,  paracentesis  should,  if  practicable,  be  performed,  and  the 
aqueous  humour  applied  to  some  other  eye  to  see  if  it  will  produce 
dilatation  of  the  pupil.  Where  the  atropine  has  only  been  applied  to  one 
eye,  the  detection  is  far  more  simple,  for  not  only  will  the  pupil  be  dilated 
ad  maximum,  but  it  will  not  act  consentaneously  with  that  of  the  other 
eye,  with  the  movements  of  the  eyes,  or  during  the  act  of  accom- 
modation (vide  the  article  Mydriasis,  p.  160).  But  there  are  several 
other  methods  of  detecting  the  simulation  of  monocular  amaurosis. 
One  of  the  best  of  these  is  Von  Graefe's  test  with  prismatic  glasses. 
Thus,  if  a  patient  complains  that  he  is  absolutely  blind  in  one  eye,  and 
the  examination  of  this  eye  is  concluded,  that  of  the  other  (both  eyes, 
however,  being  open)  should  be  proceeded  with,  and  a  prism  of  10°  or 
15°  be  held  with  its  base  upwards  or  downwards  before  the  healthy 
eye.  The  patient  should  then  be  casually  asked  (so  as  not  to  arouse  his 
suspicion  that  we  suppose  him  to  be  deceiving),  whether  this  improves 
the  sight  or  not.  If  he  says  that  it  causes  dijalopia,  the  simulation  is 
proved,  for  if  he  was  absolutely  blind  in  one  eye  diplopia  could  not  be  pro- 
duced, whereas  tHs  would  not  exclude  a  considerable  degree  of  ambly- 
opia. The  prism  should  be  turned  in  different  directions,  in  order  that 
we  may  ascertain  if  the  double  images  correspond  to  the  position  of  the 
prism. 

Dr.  Von  Welz*  places  before  one  eye  a  prism  of  10°  or  15°,  with 

*  Congress  Oplithalmologique,  1866  ;  ComjDte-Rendu. 


SIMULATION   OF   AMAUROSIS.  421 

its  base  turned  horizontally  outwards  or  inwards.  If  a  corrective 
squint  arises,  or  if,  on  removal  of  the  prism,  there  is  any  change  in  the 
position  of  the  optic  axes,  it  proves  at  once  that  the  patient  enjoys 
binocular  vision. 

Mr.  Zachariah  Laurence*  employs  the  stereoscope  for  the  purpose 
of  detecting  simulation  of  monocular  amaurosis.  The  slide  used  for 
this  purpose  has  two  different  words  or  figures  (e.g.,  a  circle  and 
quadrant)  upon  it,  so  arranged  as  to  undergo  an  optical  transposition 
when  seen  through  a  stereoscope.  Mr.  Laurence  says,  "  Where  blindness 
of  one  eye  is  simulated,  the  test  is  certain,  if  care  is  taken  not  to  let  the 
patient  see  the  slide  befoi'e  putting  it  into  the  stereoscope,  which  for  the 
purpose  should  be  enclosed  on  all  sides  with  ground  glass.  The  patient 
would,  from  the  fact  of  the  transposition,  expose  the  fraud  by  his  own 
evidence,  and  condemn  liimself  out  of  his  own  mouth." 

Javal  directs  the  patient  to  read  some  print,  and  then  places  a  ruler 
between  the  eyes  and  the  print,  in  such  a  manner  that  a  portion  of  the 
type  is  excluded  from  the  eye  which  is  stated  to  be  blind ;  the  position 
of  the  ruler  is  then  somewhat  shifted  to  the  other  side,  so  that  the 
affected  eye  can  see  the  whole  page,  and  a  portion  of  the  print  is 
excluded  from  the  healthy  eye.  If  the  patient  can  see  with  both  eyes, 
the  ruler  will  produce  no  disturbance,  whereas  if  the  one  eye  is  really 
blind,  a  part  of  the  type  will  be  rendered  invisible  to  the  sound  eye. 

*  "  Handy  Book  of  Oplithahnic  Surgery,"  17- 


Chapter   XI. 
DISEASES   OF   THE   CHOROID. 


1.— HYPEREMIA  OF  THE  CHOROID. 

A  HTPERiEMic  condition  of  the  choroid  is  by  no  means  so  easy  to 
diagnose  with  the  ophthalmoscope  as  is  often  asserted,  indeed  it  is 
frequently  quite  impossible  to  do  so.  On  the  one  hand,  the  epithelial 
layer  of  the  choroid  may  be  so  dense  as  completely  to  hide  the  choroidal 
vessels  ;  on  the  other,  the  diversities,  both  in  the  amount  and  distribution 
of  the  pigment  in  the  stroma  of  the  choroid,  are  so  various,  as  often  to 
render  it  quite  impossible  to  decide  whether  or  not  there  is  any  hyper- 
semia.  It  is  especially  difficult,  if  both  eyes  present  the  same  appear- 
ances, for  we  then  lose  the  opportunity  of  comparing  the  affected  with 
the  healthy  eye.  Hyperaemia  of  the  choroid  may  be  suspected,  if  we 
notice,  at  one  portion  of  the  fundus,  that  the  size  and  redness  of  the 
choroidal  vessels  seem  to  be  increased,  more  especially  of  their  smaller 
branches,  so  that  the  intra- vascular  spaces  appear  encroached  upon  and 
somewhat  crowded  together ;  and  more  particularly  if  these  symptoms 
have  come  on  rather  rapidly.  The  disc  may  also  look  somewhat 
flushed  and  hyperaemic.  The  external  symptoms  {e.g.,  ciliary  injection, 
dilated  and  tortuous  ciliary  veins,  etc.)  which  have  often  been  quoted 
as  being  indicative  of  hyperajmia  of  the  choroid,  are  quite  unreliable. 

2.— DISSEMINATED  OR  EXUDATIVE  CHOROIDITIS 

(Plate  II,  Fig.  4.) 

When  this  disease  is  at  all  advanced,  it  presents  most  characteristic 
and  striking  ophthalmoscopic  appearances,  which  cannot  fail  to  arrest 
the  attention  of  the  most  superficial  observer.  But  in  the  earliest 
stages  it  may  easily  be  overlooked,  more  especially  if  it  commences,  as 
is  very  frequently  the  case,  in  the  form  of  small,  circumscribed  exuda- 
tions, situated  quite  at  the  periphery  of  the  fundus.  These  small,  round 
greyish-white  spots  of  exudation  vary  much  in  size  and  shape.  In  some 
cases,  they  may  not  be  larger  than  a  millet  seed,  in  others,  they  attain 
a  considerable  magnitude.     The  larger  ones  are,  however,  generally  met 


DISSEMINATED   OR  EXUDATIVE   CHOROIDITIS.  423 

with  in  the  centre  of  the  fundus.  The  exudations  occur  both  on  the 
inner  sui'face  of  the  choroid  and  in  its  stroma.  They  are  of  a  dull, 
whitish-yellow,  or  creamy  tint,  the  epithelium  around  them  being  either 
normal,  or  but  slightly  thinned.  At  a  later  stage  the  exudations  become 
absorbed,  and  the  choroid,  perhaps,  undergoes  some  atrophic  changes, 
becoming  thinned  and  permitting  the  white  sclerotic  to  shine  through, 
which  gives  a  peculiarly  white  and  glistening  appearance  to  the  patch. 
On  the  expanse  of  the  latter,  we  may  also  sometimes  be  able  to  trace  the 
outhnes  of  the  faint  choroidal  vessels  which  traverse  it.  Around  these 
atrophic  patches,  the  epithelium  does  not  retain  its  normal  appearance, 
but  its  cells  proliferate,  increase  in  size,  and  contain  a  great  quantity 
of  pigment,  which  becomes  collected  around  the  margin  of  the  white 
figure,  in  the  form  of  a  more  or  less  broad,  irregular,  black  girdle.  The 
indiv-idual  exudations  often  increase  in  size  and  coalesce  one  with 
another,  thus  giving  rise  to  larger  patches,  which  finally  attain,  perhaps, 
a  considerable  magnitude.  From  the  periphery  of  the  fundus,  the  disease 
extends  more  and  more  towards  the  posterior  pole  of  the  eye,  so  that 
at  last  the  whole  background  of  the  eye  may  be  thickly  studded  with 
innumerable  white,  or  yellowish-white  patches  of  varying  size  and 
shape,  surrounded  by  a  deep  black  fringe,  and  perhaps  divided  from 
each  other  by  strijDS  of  healthy  choroid.  In  such  cases,  we  often  have 
an  excellent  opportunity  of  watching  side  by  side  the  various  changes 
which  the  exudations  undergo ;  from  their  first  appearance,  as  opaque, 
creamy  white  spots,  surrounded  by  unchanged  epithelium,  to  the  last 
stage  of  glistening  white,  atrophic  patches,  embraced  by  a  deep  black 
circlet  of  pigment. 

In  other  cases,  the  disease  commences  in  the  region  of  the  yellow 
spot,  sometimes  in  its  very  centre.  One  or  more  small  specks  are 
noticed,  the  centre  of  which  is  of  a  paler  red  than  the  surrounding 
choroid ;  or  the  patch  may  be  of  a  grejash  white  or  creamy  colour,  with 
perhaps  a  faint,  pale-red  areola  round  it.  The  choroid  in  the  region 
of  the  yellow  spot  is  generally  in  such  cases  of  a  somewhat  deejier  tint. 
The  white  spots  soon  increase  in  number  and  size,  are  arranged  perhaps 
in  groups,  and  gradually  extend  towards  the  circumference.  The 
periphery  of  the  choroid  may  remain  unaSected,  or  show  only  a  few 
scattered  groups  of  exudation. 

Although  we  cannot  with  certainty  diagnose  the  syphihtic  character 
of  the  disease  simply  by  the  ophthalmoscopic  symptoms,  as  we  find 
that  sometimes  the  most  varied  forms  of  this  affection  are  due  to 
syphilis,  yet  some  authors  consider  that  certain  appearances  are  more 
especially  symptomatic  of  the  specific  disseminated  choroiditis.  Thus 
Liebreich  thinks  that  the  latter  is  distinguished  by  the  fact,  that  the 
little  masses  of  exudation  are  small,  circumscribed,  isolated,  and  do  not 
show  any  tendency  to  coalesce,  even  when  they  are  grouped  closely 


424  DISEASES   OF   THE   CHOROID. 

together.  The  tissue  changes  extend  deeply  into  the  stroma  of  the 
choroid.  These  appearances  are  well  illustrated  in  the  ophthal- 
moscopic plates  (Plate  II,  fig.  4).  Von  Graefe  thinks  that  syphilitic 
disseminated  choroiditis  shows  itself  most  frequently  in  the  form  of 
numerous  circumscribed  white  patches,  with  a  pale  red  zone  around 
them,  and  occurring  at  the  posterior  pole  of  the  eye ;  and  which  but  rarely 
pass  over  into  any  other  form  of  choroiditis.  I  have  also  found  this 
form  of  choroiditis  more  frequently  associated  with  syphilis  than  any 
other.  But  yet  it  mu^st  be  admitted  that  it  may  occasionally  assume 
most  varying  appearances.  Thus  I  have  seen  cases  of  syphilitic  cho- 
roiditis in  which  a  large  bluish-grey  exudation  has  occupied  the  region 
of  the  yellow  spot,  and  around  this  were  scattered  to  a  considerable 
distance  numerous  smaller  exudations  and  atrophic  patches,  the  peri- 
phery of  the  fundus  being  almost  free  from  any  exudations.  These 
appearances  (more  especially  the  grey,  nebulous  effusion)  at  the  yellow 
spot,  were  almost  perfectly  identical  in  both  eyes. 

The  areolar  choroiditis  of  Forster*  is  distinguished  by  certain  pecu- 
har  features,  which  show  under  what  different  forms  the  disseminated 
choroiditis  may  present  itself.  I  would  therefore  rather  consider  it  as 
a  subdivision  of  this  affection,  than  as  a  special  disease.  The  spots  are 
large,  oval  or  circular,  sharply  defined,  and  of  a  white,  or  yellowish 
wliite  colour,  having  traces  of  faintly  marked  choroidal  vessels  in  their 
area.  They  are  separated  from  each  other  here  and  there  by  strips  of 
normal  choroid.  They  are  chiefly  grouped  around  the  optic  disc,  but 
are  divided  from  it  by  a  portion  of  healthy  choroid,  so  that  they  do 
not  reach  up  to  it.  Their  size  varies  considerably,  some  being  nearly 
as  large  as  the  optic  disc,  others  about  the  size  of  a  pea ;  they  always 
diminish,  however,  towards  the  periphery.  The  patches  are  surrounded 
by  a  dark  zone  of  pigment,  which  is  the  more  broad  and  marked  the 
smaller  that  the  central  white  spot  is.  Quite  at  the  periphery  of  the  group 
of  white  patches,  are  noticed  dark,  black  spots,  having  no  white  centre. 

The  diagnosis  of  disseminated  choroiditis  is  not  difficult,  and  it 
could  not  very  easily  be  mistaken  for  any  other  disease.  The  fact  that 
the  little  white  exudations  are  situated  in  the  choroid,  and  not  in  the 
retina,  may  be  easily  ascertained  by  attention  to  the  following  points, 
viz. :  the  retinal  vessels  can  be  traced  distinctly  over  them,  and  are  not 
the  least  interrupted  or  rendered  indistinct  in  their  course ;  there  are 
no  appearances  of  blood  effusions  into  the  retina,  which  generally  occur 
together  with  exudations  into  the  latter ;  the  retina  is  also  transparent, 
and  of  normal  appearance  around  the  exudations,  and  the  retinal  veins 
are  not  dilated  or  tortuous.  When  the  exudations  are  absorbed  and 
the  choroid  undergoes  atrophy,  the  patches  become  fringed  with  pig- 

*  Forster,  "  Oplithaluiologischc  Beitriige."     Berliu,  1862,  page  99. 


DISSEMINATED   OR   EXUDATIVE   CHOROIDITIS.  425 

inent,  and  upon  tlieir  expanse  can  be  noticed  remains  of  the  choroidal 
tissue  and  of  the  vessels.  Care  should  be  taken  to  distinguish  this 
form  of  pigmentation,  from  the  deposits  of  pigment  in  the  retina 
which  may  occur  in  various  forms  of  choroido-retinitis,  as  also  in  the 
disseminated  choroiditis,  in  which  the  external  layer  of  the  retina 
becomes  more  or  less  glued  against  the  choroid,  and  destroyed  or 
atrophied,  or  the  pigment  of  the  epithelial  layer  of  the  choroid 
becomes  infiltrated  into  the  retina.  In  such  cases,  the  rods  and  bulbs 
are  especially  apt  to  suffer,  but  the  changes  may  extend  deeper,  and 
even  involve  the  ganglion  cells. 

Again,  the  retina  may  suffer  by  becoming  compressed  by  the  exu- 
dations and  aggregations  of  the  pigment  cells,  and  if  this  lasts  for  any 
length  of  time,  the  retina  gradually  becomes  thinned  and  atrophied, 
being  changed  into  a  kind  of  fibrillar  tissue,  and  its  normal  elements 
rendered  quite  indistinguishable.  Thus,  consecutive  atrophy  of  the 
retina  and  optic  nerve  not  unfrequently  ensue  upon  disseminated  cho- 
roiditis. In  Plate  II,  fig.  4,  these  appearances  are  illustrated.  The 
optic  disc  is  seen  to  be  pei'fectly  atrophied,  of  a  bluish  grey  tint,  and 
utterly  devoid  of  blood-vessels,  excepting  the  two  little  t\\dgs  which 
can  just  be  discerned  running  over  its  edge.  Not  a  single  retinal 
vessel  can  be  distinguished  over  the  whole  fundus.  It  is  but  very 
seldom  that  we  meet  with  so  extreme  a  case  of  atrophy,  and  Liebreich 
supposes  that  in  all  probability  a  syphilitic  retinitis  had  co-existed  with 
the  disseminated  choroiditis. 

The  vitreous  humour  also  frequently  becomes  affected  during  the 
progress  of  the  disease  ;  indeed  floating  or  fixed  opacities  in  it  are  some- 
times the  first  or  even  the  only  premonitory  symptoms,  which  call  the 
patient's  attention  to  his  eye.  I  have  met  with  several  cases,  in  which 
a  few  small  floating  opacities  in  the  vitreous  humour  formed  the  first 
symptom,  there  being  at  that  time  no  trace  of  disseminated  choroiditis 
to  be  detected  by  the  most  careful  ophthalmoscopic  examination.  But 
some  time  afterwards,  small  circular  patches  made  their  appearance 
in  the  choroid.  Sometimes,  however,  the  vitreous  does  not  become 
affected  tiU  a  late  stage  of  the  disease,  and  it  may  then  be  so  diffusely 
clouded  as  to  render  the  details  of  the  fundus  quite  indistinct,  or  be 
traversed  by  large,  dark,  floating  or  fixed  membranous  filaments.  Sub- 
sequently a  posterior  polar  cataract  is  often  formed. 

The  iris  sometimes  becomes  inflamed,  but  hardly  ever  to  a  considerable 
decree,  there  being  only  a. few  delicate  synechiae,  and  very  little  alteration 
in  the  structure  of  the  iris.  The  inflammation  often  assumes  a  serous  cha- 
racter, and  small  opacities  are  noticed  on  the  posterior  wall  of  the  cornea. 
The  external  appearance  of  the  eye  is  generally  quite  normal ;  there  is 
hardly  any  conjunctival  or  subconjunctival  injection,  photophobia, 
or  lachrymation,    and  little    or  no  pain ;  the  pupil  being  often  of  a 


426  DISEASES   OF   THE   CHOROID. 

normal  size,  or  but  little  dilated  ;  and  yet  the  sight  may  be  greatly 
impaired ;  and  it  is  only  with  the  ophthalmoscope  that  we  detect  the 
great  and  striking  changes  in  the  fundus. 

The  sight  is  often  very  considerably  affected,  the  patient  complaining 
of  a  dark  cloud,  or  of  black,  fixed,  and  floating  objects  before  his  eyes. 
These  scotomata  are  either  due  to  diffuse  and  floating  opacities  in  the 
vitreous  humour,  or  to  injuries  which  the  retina  has  sustained  by  com- 
pression or  destruction  of  some  of  its  elements.  The  impaLrment  of 
vision  will,  of  course,  be  proportionately  greater,  if  the  disease  is 
situated  at  the  posterior  pole  of  the  eye,  than  if  it  be  confined  to  the 
periphery  of  the  fundus.  In  the  former  situation,  a  very  small  and 
circumscribed  group  of  exudations  may  sufiice  to  destroy  central  vision ; 
in  the  latter,  even  considerable  deposits  raay  not  materially  affect  the 
sight,  except  in  the  outline  of  the  field.  Not  only  does  the  central 
vision  suffer  as  regards  distinctness,  when  the  exudations  occurjn  the 
region  of  the  yellow  spot,  but  the  objects  appear  distorted  and  crooked 
(metamorphopsia),  on  account  of  the  compression  and  alteration  in  the 
arrangement  of  the  retinal  elements.  We  sometimes  notice  a  marked 
improvement  in  the  sight,  when  the  exudations  are  absorbed  and  the 
pressure  diminished,  but  of  course  this  can  only  occur  if  the  retinal 
elements  have  not  suffered  too  much,  or  for  too  long  a  period. 

The  field  of  vision  is  frequently  considerably  contracted,  and  shows 
more  or  less  extensive  interruptions  (scotomata)  within  its  area. 

The  prognosis  of  the  disease  must  always  be  extremely  guarded, 
more  especially  if  the  exudations  appear  in  the  region  of  the  yellow 
spot.  Of  these,  the  httle  spots  surrounded  by  a  pale-red  rim,  which 
are  so  characteristic  of  syphilis,  afibrd  comparatively  the  best  prog- 
nosis. 

In  the  most  favourable  cases  the  exudations  may  become  absorbed, 
leaving  behind  them  only  faint  traces  of  a  change  in  the  epithelial 
layer,  in  the  form  of  light  red  patches  in  which  the  choroidal  vessels 
can  be  distinctly  traced ;  or  they  may  give  rise  to  somewhat  deeper 
cicatrices.  More  frequently,  however,  they  produce  extensive  atrophy 
of  the  stroma  of  the  choroid,  which  is  especially  apt  to  be  injurious  to 
the  sight  if  the  exudations  are  large,  situated  in  the  region  of  the  yellow 
spot,  and  coalesce  together  so  as  to  form  extensive  atrophic  patches. 
Moreover,  in  forming  our  prognosis  we  must  always  bear  in  mind 
that  the  retina  is  very  prone  to  suffer,  both  from  direct  corapression  of 
its  elements  and  from  their  destruction  (more  especially  the  rods  and 
bulbs)  from  becoming  glued  to  the  choroid,  and  pigment  being  infil- 
trated thence  into  the  retina.  Atrophy  of  the  retina  and  optic  nerve  are 
therefore  not  an  unfrequent  consequence  of  disseminated  choroiditis. 

The  causes  of  this  disease  are  often  obscure,  but  by  far  the  most 
frequent  is  syphilis.     The  insidious  choroiditis,  which  is  accompanied 


SCLEROTICO-CHOROIDITIS  POSTERIOR.  427 

by  serous  iritis,  is  sometimes  observed  in  delicate,  scrofulous,  or  con- 
sumptive individuals. 

The  treatment  m.ust  consist  chiefly  in  the  administration  of  mercu- 
rials. Indeed  the  inflammatory  diseases  of  the  choroid  appear  to  be 
most  beneficially  influenced  by  small  doses  (gV  or  -Jg^  of  a  grain  2  or  3 
times  daily)  of  the  bichloride  of  mercury,  continued  for  a  very  long 
period.  If  there  are  distinct  evidences  of  syphilis,  and  if  the  disease  is 
rapid  in  its  progress,  salivation  should  be  quickly  induced,  so  as,  if 
possible,  to  check  the  further  eSusion  of  lymph  and  hasten  the  absorp- 
tion of  that  already  exuded.  If  this  be  not  done,  larger  doses  of  the 
bichloride,  in  combination  with  the  iodide  of  potassium,  should  be  given. 
The  artificial  leech  should  be  applied  occasionally,  but  if  the  patient  is 
very  feeble  but  little  blood  should  be  taken,  or  dry  cupping  should  be 
substituted.  He  must  be  strictly  ordered  to  abstain  from  all  use  of  the 
eyes  in  reading,  etc.,  and  they  should  be  guarded  against  bright  light 
by  the  employment  of  blue  glasses.  If  the  functions  of  the  liver,  uterus, 
or  digestive  organs  are  out  of  order,  these  should  be  attended  to ;  and 
much  benefit  is  often  experienced  from  the  use  of  mildly  purgative 
mineral  waters,  such  as  the  Pullna,  Marienbad,  Karlsbad,  etc. 

3.— SCLEROTICO-CHOROIDITIS  POSTERIOR  (POSTERIOR 
STAPHYLOMA,  SCLERECTASIA  POSTERIOR).  Plate  II, 
Fig.  3. 

This  disease  is  but  seldom  absent  in  the  more  considerable  degrees 
of  myopia,  and  mnst  be  regarded,  more  especially  if  it  is  progressive,  as 
a  more  or  less  serious  compKcation. 

Eyes  affected  with  sclerotico-choroiditis  posterior  generally  appear 
to  be  abnormally  large,  prominent,  and  ovoid  in  shape.  The  palpebral 
aperture  is  widely  open,  which  is  especially  conspicuous  if  only  one 
eye  is  afiected.  The  eyeball  also  appears  lengthened  in  its  antero- 
posterior diameter,  and  the  infundibulum  or  hollow,  which  is  seen  in  the 
normal  eye  (when  it  is  much  turned  in)  between  the  outer  canthus 
and  the  globe,  has  disappeared ;  so  that  the  posterior  segment  of  the 
eyeball  appears  lengthened  and  square,  and  perhaps  of  a  slightly  bluish 
tint.  The  lateral  movements  of  the  eye  may  be  somewhat  curtailed  if 
the  disease  is  extensive.  The  patients  often  complain  of  a  feeling  of 
tension  and  fulness  in  the  eyeball,  as  if  the  latter  were  too  large  for  the 
socket,  and  there  may  also  be  pain  in  and  around  the  eye. 

The  disease  can,  however,  only  be  diagnosed  with  certainty  with  the 
ophthalmoscope ;  for  a  considerable  posterior  elongation  of  the  eyeball 
(posterior  staphyloma)  may  exist  without  any  appearance  of  sclerotico- 
choroiditis  posterior. 

The  ophthalmoscopic  symptoms  are  generally  very  marked  and  un- 
mistakeable.     The  characteristic  symptom  is  a  brilliant  white  or  pale 


428  DISEASES   OF   THE   CHOROID. 

yellow  crescent  at  the  edge  of  the  optic  disc,  generally  at  the  outer  side 
(in  the  reverse  image  it  will  of  course  appear  towards  the  nasal  side). 
This  crescent  may  vary  much  in  size,  from  a  small  white  arc  to  a 
large  zone,  and  extends  perhaps  all  round  the  disc  and  embraces  even 
the  region  of  the  yellow  spot,  its  greatest  extent  being  always  in  the 
direction  of  the  latter.*  Its  edges  may  be  either  sharply  and  distinctly 
defined,  or  may  be  irregular,  and  gradually  lost  in  the  surrounding 
healthy  structures  ;  irregular  patches  of  pigment '  are  strewn  about  its 
margin,  and  also,  perhaps,  on  its  surface,  so  that  little  dark  islets  of 
varyiuo-  size  and  form  appear  in  its  expanse.  The  crescent  itself  is  of 
a  brilliant  white,  so  much  so  indeed,  that  the  disc,  by  contrast,  appears 
to  be  abnormally  pink.  On  account  of  the  white  background,  the  small 
retinal  vessels  can  be  traced  more  distinctly,  and  their  minute  branches 
be  more  easily  followed  over  this  patch  than  in  the  neighbouring  fundus. 
This  white  crescent  is  due  to  a  thinning  and  atrophy  of  the  stroma  of 
the  choroid,  indeed  the  latter  has  occasionally  been  found  quite  wanting 
in  this  situation.  The  pigment  cells  are  not  necessarily  desti-oyed,  but 
there  is  an  absence  of  pigment  molecules,  for  the  h-regular  black  patches 
mentioned  above  are  pathological  agglomerations  of  pigment.  On 
account  of  the  loss  of  pigment  and  the  atrophy  or  thinning  of  the 
stroma  of  the  choroid,  the  glistening  sclerotic  shines  through  the  latter, 
and  lends  the  brilliant  white  appearance  to  the  figure.  This  want  of 
pigment  also  gives  rise  to  the  sense  of  glare,  which  the  patient  expe- 
riences in  a  bright  light.  The  amblyopia  which  frequently  exists  in 
this  disease,  is  also  undoubtedly  partly  due  to  this  fact,  for  we  find  that 
the  sio-ht  of  such  patients  is  often  remarkably  benefited  by  blue  spec- 
tacles. The  amblyopia,  however,  as  a  rule,  depends  chiefly  upon  the 
disturbance  in  the  intra-ocular  circulation,  produced  by  the  state  of 
chronic  congestion  of  the  venous  system  of  the  eye.  Hence  we  find 
that  vision  is  generally  greatly  improved  by  depletion,  and  more 
especially  by  the  artificial  leech. 

The  retina  generally  suffers  only  in  so  far  from  this  loss  of  pigment 
in  the  choroid,  that  a  slight  diminution  in  the  distinctness  of  percep- 
tion is  produced.  The  "  blind  spot  "  (answering  to  the  optic  entrance) 
is  somewhat  enlarged,  but  this  increase  does  not  correspond  at  all  to 
the  size  of  the  crescent,  and  vision  is  only  impaired,  not  destroyed,  in 
this  extra  portion  of  the  blind  spot.  But  sometimes  there  arises  a  state 
of  great  irritability  of  the  retina,  producing  considerable  amblyopia 

*  Wo  must,  however,  be  careful  not  to  call  every  little  white  rim  at  the  edge  of 
the  disc  sclerotico-choroiditis  posterior,  for  this  may  be  caused  simply  by  the  choroid 
receding  somewhat  from  the  optic  nerve,  and  permitting  the  hght  to  faU  at  this 
spot  tlirough  the  retina  upon  the  denuded  sclerotic,  thus  affording  the  appearance 
of  a  white  glistening  rim.  But  this  arc  is  very  narrow,  and  there  are  no  appear- 
ances of  atrophy  of  the  choroid,  or  irregular  patches  of  pigment  at  its  edges. 


SCLEROTICO-CHOROIDITIS  POSTERIOR.  429 

and  disturbance  of  vision,  togctliei*  with  photopsia  and  a  feeling^of  pain 
and  tension  within  the  eye  on  the  slightest  exei^tion  in  reading,  etc. 

The  disease  may  remain  stationary  or  progress.  In  the  former  case 
the  myopia  does  not  increase,  the  cir cum- orbital  and  intra-ocular  pains 
diminish  or  cease,  and  with  the  ophthalmoscope  we  find  that  there  is 
no  augmentation  in  the  size  of  the  crescent,  and  that,  perhaps,  a  regular 
deposit  of  pigment  again  takes  place. 

Far  different  is  it  if  the  disease  progresses,  which  is  generally  the 
case  when  the  atrophy  is  at  all  advanced.  The  myopia  is  then  found  to 
increase  more  or  less  rapidly,  vision  becomes  dimmed  or  greatly  im- 
paired, the  patients  are  often  continually  haunted  by  "  blacks  "  floating 
before  their  eyes,  which  may  assume  all  kinds  of  fantastic  shapes,  and 
are  due  to  opacities  in  the  vitreous  humour.  At  other  times,  they  are 
greatly  disturbed  by  showers  of  bright  stars  and  flashes  of  light,  which 
are  due  to  a  state  of  irritation  of  the  optic  nerve  and  retina  ;  and  they 
become  more  and  more  dazzled  by  the  light  on  account  of  the  increased 
atrophy  of  the  choroid  and  the  loss  of  pigment.  But  the  progress  of 
the  affection  is  best  Avatched  with  the  ophthalmoscope.  The  edges  of 
the  crescent  show  symptoms  of  hypersemia,  and  become  irregular  and 
ill-defined.  Small  white  patches  appear  around  it  (symptomatic  of  the 
progressive  atrophy  of  the  choroid),  and  these,  gradually  increasing  in 
size,  coalesce  with  each  other  and  with  the  original  crescent,  so  that  the 
latter  may  in  time  extend  completely  round  the  disc,  which  thus 
becomes  embedded  in  a  more  or  less  broad,  white,  glistening  ring, 
which  extends  chiefly  in  the  direction  of  the  yellow  spot.  In  such  cases, 
a  superficial  observer  might  suppose  that  the  optic  disc  was  greatly 
enlarged,  or  even  that  the  optic  nerve  (from  the  white  appearance)  was 
atrophied.  On  closer  examination,  however,  the  distinction  between  the 
disc  and  the  white  zone  is  easy,  for  the  entrance  of  the  optic  nerve  looks 
abnormally  pink,  on  account  of  the  contrast  with  the  bright  wliite  of  the 
surrounding  ring,  and  its  vessels  are  more  easily  traceable  over  the 
latter  than  on  the  disc. 

A  similar  process  may  also  occiu'  in  the  region  of  the  yellow  spot. 
Little  white  patches  appear,  which  increase  in  size  and  coalesce,  giving 
the  whole  an  appearance  of  alternate  white  and  dark  reticulated  spaces, 
the  white  spots  being  due  to  the  sclerotic  shining  through  the  atrophied 
stroma  and  pigment  layer  of  the  choroid.  Von  Graefe  thinks  that  the 
retina  may  in  this  situation  participate  more  rapidly  in  the  disease  than 
otherwise,  on  account  of  its  being  thinner  at  this  spot.  If  the  atrophy 
of  the  choroid  in  the  region  of  the  macula  lutea,  as  well  as  that  around 
the  optic  entrance,  progress,  the  two  separate  processes  may  gradually 
extend  towards  each  other  (leaving  less  and  less  healthy  structure 
between  them),  until  they  finally  pass  into  each  other,  and  form  one 
large  white  figure. 


430  DISEASES   OF   THE   CHOROID. 

The  occurrence  of  the  disease  at  the  macula  lutea  generally  causes 
great  impairment  of  vision,  and  the  patients  then  also  complain  of  the 
constant  appearance  of  one  or  more  central,  fixed,  dark  spots  (scotomata) 
in  the  field  of  vision.  It  should  be  remarked,  that  they  may  be  appa- 
rent to  the  patient  long  before  we  are  able  to  detect  with  the  ophthal- 
moscope any  corresponding  changes  in  the  region  of  the  yellow  spot. 

Von  Graefe*  has  called  attention  to  the  important  fact  that  glau- 
coma may  supervene  upon  sclerotico-choroiditis  posterior,  and  lead  to 
great  impairment  of  vision,  or  even  blindness.  The  eye  becomes  hard, 
the  ciliary  vessels  injected,  the  anterior  chamber  more  shallow,  the 
pupil  dilated.  The  edge  of  the  disc  contiguous  to  the  arc  becomes 
sharply  defined  and  slightly  excavated,  and  the  vessels  somewhat  dis- 
placed and  curved  as  they  pass  over  it.  The  cup  extends  quite  up  to 
the  margin  of  the  disc,  which  distinguishes  it  from  the  physiological 
form.  Tliis  glaucomatous  complication  occurs  chiefly  in  elderly  persons, 
and  is  probably  due  to  the  fact  that  the  sclerotic,  losing  some  of  its 
elasticity  with  advancing  age,  cannot,  as  heretofore,  yield  to  the  increased 
intra-ocular  pressure,  and  hence  the  latter  now  exerts  a  deleterious 
efiect  upon  the  optic  nerve,  and  causes  it  to  become  cupped.  It  is  also 
sometimes  met  with  in  young  individuals.  The  increased  tension  is, 
as  a  rule,  not  considerable  in  degree.  Generally  both  eyes  are  simul- 
taneously attacked.  Iridectomy  should  be  performed  at  an  early  stage, 
as  no  other  remedy  will  stay  the  progress  of  the  disease. 

Complications. — Vitreous  opacities  are  of  very  frequent  occurrence 
in  sclerotico-choroiditis  posterior,  and  are  often  a  source  of  great 
anxiety  to  the  patient,  for  even  the  physiological  motes  are  rendered 
very  distinct  in  short-sighted  eyes,  on  account  of  the  circles  of  diflPu- 
sion  upon  the  retina.  The  vitreous  opacities  may  be  dark,  fixed  specks, 
or  floating  membranous  films  of  varying  size  and  shajDC  (vide  article  on 
Opacities  of  the  Vitreous  Humour,  p.  315). 

Detachment  of  the  retina  is  unfortunately  another  not  unfrequent 
complication  of  the  more  considerable  degrees  of  sclerotico-choroiditis 
postei*ior.  Its  extent  may  be  at  first  but  slight,  and  be  produced  by  a 
serous  or  hsBmorrhagic  effusion  between  the  choroid  and  retina;  or  it  may 
be  caused  by  the  contraction  of  some  of  the  exudations  in  the  vitreous 
humour  exerting  traction  upon  the  retina,  and  thus  detaching  itf 
(vide  article  on  Detachment  of  Retina,  p.  358). 

Opacity  at  the  posterior  pole  of  the  lens  sometimes  occurs  in  the  later 
stages  of  the  disease.  This  opacity  is  generally  situated  very  close  to 
the  turning  point  of  the  eye,  and  hence  remains  immoveable,  although 
the  eye  is  turned  in  a  different  direction.  Cataracta  aecreta,  irido-cho- 
roiditis,  and  atrophy  of  the  globe  may  close  the  scene. 

*  "  A.  f.  O.,"  iv,  2,  153  ;  and  ib.,  viii,  2,  304. 
t  Heinrich  MuUer,  ib.,  iv,  I,  372. 


SCLEROTICO-CHOROIDITIS   POSTERIOR.  431 

Causes. — The  origin  of  the  affection  is  still  a  matter  of  controversy. 
Without  doubt,  there  generally  exists  a  congenital  (and  often  here- 
ditary) tendency  to  elongation  of  the  eyeball  in  the  optic  axis  ;  and  this 
must  necessarily  cause  a  stretching  of  the  choroid  in  this  direction, 
which  is  generally  soon  followed  by  consecutive  atrophy  of  this  mem- 
brane. The  development  of  this  prolongation  of  the  visual  axis  is 
greatly  favoured  by  the  strong  convergence  of  the  optic  axes,  and  the 
state  of  congestion  of  the  eye  which  is  produced  during  accommodation 
for  near  objects,  more  particularly  if  these  are  small  and  insufficiently 
illuminated.  For  during  such  accommodation,  a  certain  pressure  upon 
the  eye  always  occurs,  accompanied  by  increased  intra-ocular  pressure  ; 
in  consequence  of  which  the  venous  circulation  within  the  eye  becomes 
retarded,  and  a  more  or  less  considerable  state  of  mechanical  congestion 
is  produced.  Instances  of  such  intra-ocular  congestion  are  furnished  by 
cases  of  amblyopia  due  to  opacities  of  the  cornea  or  lens,  in  which  the 
myopia  is  caused  by  the  patient's  bringing  small  objects  very  near  to 
the  eye,  in  order  to  gain  larger  retinal  images.  A  similar  thing  may  occur 
if  the  patient,  whilst  using  concave  spectacles  for  reading,  gradually 
approaches  the  book  too  near  to  his  eyes.  We  occasionally  find  that 
vitreous  opacities,  and  even  detachment  of  the  retina,  occu.r  in  such 
cases  soon  after  long-continued  reading  or  working  with  spectacles. 

This  state  of  congestion  and  increased  pressure  of  the  intra-ocular 
fluids  lead  to  softening  and  extension  of  the  tunics  of  the  eyeball.  As 
the  latter  receives  no  support  at  the  posterior  pole  from  the  muscles, 
the  prolongation  occurs  chiefly  at  this  poiat,  the  choroid  being  stretched 
and  generally  undergoing  consecutive  atrophy. 

This  secondary  atrophy  of  the  choroid,  which  gives  rise  to  the 
crescentic  white  patch  at  the  margin  of  the  optic  disc,  has  been  con- 
sidered by  Yon  Graefe  to  be  most  likely  due  to  a  chronic  inflammation 
of  the  sclerotic  and  choroid,  and  he  has,  therefore,  designated  it  slerotico- 
choroiditis  posterior.  Others  again,  have  thought  that  it  depends  upon 
a  circumscribed  staphylomatous  bulging  of  the  sclerotic  at  this  point, 
and  hence  have  termed  it  staphyloma  posticum.  But  against  both 
these  opinions  exception  might  be  taken. 

This  choroidal  atrophy  may,  however,  exist  without  any  posterior 
staphyloma.  Indeed,  Schweigger  states  that  a  real  staphyloma  posti- 
cum, i.e.,  a  more  or  less  sharply  defined  local  ectasia  of  the  walls  of  the 
eyeball,  does  not  take  place  in  the  majority  of  cases  of  myopia.  The 
presence  of  a  posterior  staphyloma  may  be  diagnosed  by  means  of  the 
ophthalmoscope,  particularly  with  the  binocular,  for  we  then  see  that 
the  white,  shining  portion  of  the  sclerotic  exposed  through  the  thinning 
of  the  choroid  is  not  of  normal  curvature,  but  is  peculiarly  cupped 
backwards,  giving  rise  at  this  part  to  a  slanting  position  of  the  optic 
disc.     Schweigger,  moreover,  thinks  that  the  acuteness  of  vision  is 


432  DISEASES   OF   THE   CHOROID. 

dirainished  to  anuniisiial  degree  in  those  cases  of  myopia,  in  which  pos- 
terior staphyloma  exists  beside  the  optic  nerve.  This  is  the  more  likely 
to  happen,  as  he  has  observed  that  in  cases  in  wliicli  the  existence  of  a 
posterior  staphyloma  was  proved  anatomically,  the  retina  in  the  exj)anse 
of  the  bulging  portion  was  generally  found  to  be  more  or  less  changed 
in  structure,  and  even  atrophied  and  adherent  to  the  remains  of  the 
choroid  and  sclerotic. 

In  opposition  to  Von  Graefe's  view,  it  has  been  urged  that  all  symp- 
toms of  irritation  and  inflammation  are  frequently  completely  absent, 
at  least  at  the  commencement  of  the  affection,  and  that  the  latter  may 
even  attain  a  considerable  degree  without  their  occurrence.  But  there 
is  no  doubt  that  such  symptoms  are  almost  always  developed  when  the 
disease  becomes  considerable,  and  the  myopia  is  high  in  degree.  In  the 
slightest  forms  they  may  be  easily  overlooked,  but  even  in  moderate 
degrees  of  myopia,  and  in  youthful  individuals,  we  not  unfrequently 
observe  symptoms  of  irritation,  such  as  hyperaemia  of  the  optic  nerve, 
retina,  and  choroid,  and  it  appears  probable  that  a  state  of  irritation, 
if  not  of  inflammation,  exists  prior  to  the  atrophy.  Bonders*  thinks, 
"  that  almost  without  exception,  the  predisposition  to  the  development 
of  staphyloma  posticum  exists  at  birth;  that  it  is  developed  with 
symptoms  of  irritation,  which,  in  a  moderate  degree,  do  not  attain  any 
great  clinical  importance ;  but  that  in  the  higher  degrees  an  inflam- 
matory state  almost  always  occurs,  at  least  at  a  somewhat  more  ad- 
vanced time  of  life,  as  a  result,  and  as  a  co-operative  cause  of  the 
development  of  the  distension  and  of  the  atrophy." 

Jagerf  considei^s  that  this  crescent  or  posterior  staphyloma,  as  he 
terms  it,  is  almost  always  congenital  and  often  hereditary.  It  may, 
indeed,  exist  for  many  years,  or  even  throughout  life,  without  increasing 
in  size,  or  without  the  occurrence  of  any  choroidal  changes  in  its 
vicinity,  its  margin  remainiug  distinctly  and  sharply  defined.  But  we 
more  frequently  find-if  the  eyes  are  much  used  and  the  myopia  in- 
creases at  all  considerably  in  degree,  that  the  edge  of  the  crescent 
becomes  somewhat  u-regular  and  broken,  and  gradually  increases  in 
size ;  this  being  evidently  due  to  inflammatory  changes  in  the  choroid. 
Indeed  it  may  well  be  questioned  whether  even  the  congenital  crescents 
may  not  be  of  inflammatory  origin. 

Prognosis. — This  should  be  always  very  guarded  when  the  disease 
is  at  all  advanced,  when  the  myopia  is  progressive,  and  when  the 
opacities  in  the  vitreous  humour  are  considerable.  It  becomes  still 
more  questionable  if  the  vitreous  opacities  are  diffuse,  or  large  and 
numerous,  if  the  upper  or  lower  portion  of  the  visual  field  becomes 
clouded,  which'  is  premonitory  or  symptomatic  of  detachment  of  the 

*  "Anoiiiiilics  of  Refraction  and  Accommodation,"  p.  384. 

+  "  Ueber  die  Eiustcllung  des  dioptrisclicn  Apparates."     Vienna,  1861. 


SGLEROTICO-CHOROIDITIS   POSTERIOR.  433 

retiua ;  and,  lastly,  if  the  clioi'oidal  changes  make  their  appearance  in 
the  region  of  the  yellow  spot.  They  show  themselves  in  the  form  of 
small,  isolated,  whitish  spots,  around  the  edges  of  which  there  are  little 
accumulations  of  pigment ;  these  small  whitish  spots  increase  in  size,  and 
coalesce,  and  then  the  atrophy  of  the  choroid  becomes  very  apparent. 
During  this  process,  the  retina  is  more  or  less  irritated,  and  this  pro- 
duces dimness  of  vision,  which,  however,  disappears  again  when  the 
retinal  irritation  subsides.  These  atrophic  changes  in  the  region  of  the 
yellow  spot,  give  rise  to  fixed  black  spots  in  the  visual  field,  which,  if 
considerable,  may  render  working  at  small  objects  impossible.  The 
changes  in  the  macula  lutea  generally  commence  first  in  one  eye,  and 
may  for  a  time  be  confined  to  it,  but  sooner  or  later  they  mostly  extend 
also  to  the  other  eye. 

Treatment. — Patients  sufiering  from  sclerotico-choroiditis  posterior 
should  be  particularly  warned  against  working  for  any  length  of  time 
at  near  objects,  or  with  their  head  bent  forward,  for  intra-ocular  venous 
congestion  is  thus  easily  produced.  It  is  also  very  injurious  to  read 
in  a  recumbent  position.  The  best  posture  for  reading  is,  to  sit  with 
the  head  thrown  back,  and  to  have  the  light  falling  on  the  book  from 
behind,  so  that  the  page  may  be  well  illuminated,  but  the  eye  not 
exposed  to  the  direct  glare  of  the  light.  In  writing,  it  is  advantageous 
to  use  a  sloping  desk,  so  that  the  person  need  not  stoop.  If  such 
patients  are  permitted  the  use  of  spectacles  for  reading  and  writing,  we 
must  particularly  point  out  the  danger  of  bringing  the  object  too  near 
when  the  eye  becomes  somewhat  fatigued,  as  this  will  cause  a  strain  of 
the  accommodation.  The  work  or  book  should  then  be  laid  aside,  until 
the  eyes  have  been  thoroughly  rested.  In  extreme  cases,  we  should 
strictly  forbid  all  work  at  near  objects,  either  with  or  without 
spectacles. 

The  irritation  of  the  retina  which  gives  rise  to  the  appearance  of 
flashes  of  coloured  light,  or  showers  of  bright  stars,  etc.,  is  best  relieved 
by  the  application  of  flying  blisters  to  the  temple  or  behind  the  ear. 
They  may  be  with  advantage  repeated  at  intervals  of  six  or  eight  days. 

The  feeling  of  glare  and  dazzling,  of  which  many  of  these  patients 
complain  when  they  are  in  a  bright  light,  and  which  often  produces 
severe  ciUary  neuralgia  and  headache,  is  eSectually  alleviated  by  the 
use  of  blue  sjDectacles. 

If  the  inflammatory  changes  in  the  choroid  are  at  all  considerable 
or  progressive,  we  should  always  prescribe  a  prolonged  course  of  small 
doses  of  the  bichloride  of  mercury  (one-twentieth  to  one-twenty- fourth 
of  a  grain).  Derivatives  acting  on  the  skin  and  kidneys,  and  hot 
stimulating  foot-baths  at  night  also  prove  beneficial. 

If  the  eye  is  very  irritable,  the  external  tunics  of  the  eyeball 
injected,  the  optic  disc  reddened  and  hyperaemic,  and  if  the  patient 

2   F 


434  DISEASES  OF   THE   CHOROID. 

experiences  pain  in  and  around  the  eye,  together  with  a  feeling 
of  weight  and  heaviness  in  the  eyeball,  as  if  he  can  hardly  keep 
his  eyelids  open,  we  must  insist  upon  a  complete  rest  of  the  eyes, 
and  an  absohite  cessation,  for  some  length  of  time,  from  all  working 
at  near  objects.  We  must  be  extremely  stringent  in  the  enforcement 
of  such  directions,  as  the  patients  are  too  apt  to  resume  work  as  soon  as 
their  eyes  feel  a  little  better,  and  then  at  once  call  up  again  all  the 
symptoms  of  irritation  and  congestion,  which  may  cause  a  rapid  increase 
of  the  myopia  and  of  any  existing  sclerotico- choroiditis  posterior.  Such 
cases  are  also  much  benefited  by  the  use  of  stimulating  lotions  to  the 
closed  eye  and  its  vicinity,  by  the  eye- douche  and  by  the  appHcation  of 
the  artificial  leech.  The  greatest  benefit  is  generally  found  from  the 
use  of  the  latter.  I  have  often  been  able  by  its  application  to  relieve 
the  irritation  of  the  eye,  and  the  peculiar  and  very  distressing  feeling  of 
heaviness  and  aching  in  the  eyeball,  when  all  other  forms  of  treatment 
had  proved  of  no  avail.  But  when  the  disease  is  very  considerable,  and 
when  there  is  any  fear  of  a  detachment  of  the  retina,  its  tise  is  often 
dangerous,  for  the  sudden  relief  of  the  intra-ocular  circulation  is  followed 
by  a  severe  reaction,  and  temporary  hyperemia  of  the  vessels  of  the 
choroid  and  retina ;  and  hence  an  effusion  of  blood  may  take  place  and 
produce  detachment  of  the  retina. 

4— SUPPURATIVE    CHOROIDITIS.     (PANOPHTHALMITIS). 

The  course  of  this  disease  is  generally  very  rapid  and  severe.  It 
commences  in  the  form  of  an  acute  and  violent  inflammation  of  the  eye. 
The  eyelids  become  very  swollen,  red,  and  oedematous,  the  upper  lid 
hanging  down  in  a  large  massive  fold.  The  conjunctiva  and  subcon- 
junctival tissue  become  injected,  and  there  is  a  considerable,  firm,  gela- 
tinous chemosis,  which  suiTOunds  the  cornea  like  a  dusky-red  girdle, 
and  perhaps  protrudes  between  the  apertiu-e  of  the  eyelids  when  they 
are  slightly  opened.  Thin  muco-purulent  discharge  oozes  out  between 
the  lids,  but  sometimes  it  is  absent,  and  the  edges  of  the  lids  and  the 
chemotic  swelling  look  dry  and  crusted.  On  opening  the  eye,  we  may 
find  that  the  cornea  is  quite  clear,  but  the  anterior  chamber  is  diminished 
in  size,  and  occupied,  joerhaps,  by  a  more  or  less  considerable  hypopyon  ; 
the  aqueous  humour  is  clouded,  the  iris  pushed  forward,  discoloured, 
and  of  a  yellowish  hue ;  the  pupil  is  sometimes  dilated,  in  other  cases 
of  a  normal  size  or  slightly  contracted  and  tied  down  by  lymph,  or  its 
area  occluded.  The  tension  of  the  eye  is  often  increased,  and  it 
is  acutely  sensitive  to  the  touch  ;  it  is  also  prominent  and  its  move- 
ments are  greatly  impeded,  on  account  of  the  infiltration  into  the  sub- 
conjunctival tissue.  If  the  refmctive  media  and  the  pupil  are  sufficiently 
clear,  we  observe  a  peculiar,  yellowish,  golden  reflex  from  behind  the 


SUPPURATIVE   CHOROIDITIS.  4o5 

lens,  in  tlie  anterior  portion  of  the  vitreous  hiimour,  which  is  due  to 
a  pui'ulent  infiltration  of  the  latter.  The  retina  may  become  infil- 
trated with  serum,  or  undergo  suppurative  changes,  and  the  latter 
also  extensively  affect  the  choroid  and  ciliary  body.  These  changes 
cannot  be  seen  with  the  ophthalmoscope,  on  account  of  the  exudation 
into  the  pupil,  or  the  opaque  condition  of  the  vitreous  humour. 
There  is  often  a  serous  effusion  from  the  choroid,  which  causes 
either  a  circumscribed  or  complete  detachment  of  the  retina,  or  this 
may  be  produced  by  hemorrhagic  effusion  from  the  choroid.  More- 
over, it  must  be  remembered  that,  together  with  this  pressure  of  serum 
or  blood  behind  the  retina,  the  contraction  and  shrinking  of  the  exuda- 
tions in  the  vitreous  humour,  and  the  consequent  ti-action  upon  the 
retina  from  in  front,  tend  to  produce  a  very  extensive  detachment, 
generally  of  a  funnel  shape.  Indeed,  although  the  detachment  may  for 
a  time  remain  partial  and  circumscribed,  it  almost  always  becomes 
complete  as  the  disease  advances. 

The  cornea  may  remain  transparent  throughout,  but,  as  a  rule,  it 
becomes  clouded,  infiltrated  with  pus,  and  then  gives  way,  shrivelling 
up  into  a  Uttle  yellowish  membrane,  like  wash  leather  ;  or  it  may 
remain  entire,  and  a  spontaneous  perforation  of  the  eyeball  occur 
through  the  scldl'otic,  generally  at  or  between  the  insertion  of  the  recti 
muscles.  The  disease  is  mostly  accompanied  by  very  intense  pain  in  and 
around  the  eye,  which  often  extends  over  the  corresponding  side  of  the 
head  and  face.  It  is  frequently  most  agonizing,  until  the  eyeball  per- 
forates, or  paracentesis  is  performed,  on  which  it  rapidly  subsides.  There 
are  often  also  marked  febrile  symptoms,  accompanied,  perhaps,  by  severe 
vomiting.  In  other  cases,  the  inflammatory  symptoms  and  the  pain  are 
far  less  pronounced,  and  the  whole  coui'se  of  the  disease  is  more 
insidious  and  of  a  milder  type,  although  its  results  may  be  just  as 
disastrous.  The  sight  becomes  rapidly  and  very  greatly  impaired,  so 
that  the  patient  may  only  just  be  able  to  distinguish  between  light  and 
dark,  or  not  even  this.  He  is,  moi-eover,  much  troubled  by  subjec- 
tive flashes  of  light,  showers  of  bright  stars,  etc. 

Amongst  the  most  frequent  causes  of  suppurative  choroiditis  are 
injuries*  and  wounds  of  the  eye,  and  the  lodgement  of  foreign  bodies, 
more  especially  portions  of  gun  cap  or  metal,  within  the  eyeball,  par- 
ticularly in  the  ciliary  body  and  vitreous  humour ;  such  cases  being  often 
accompanied  by  very  severe  inflammatory  symptoms  and  intense  pain. 
Although  foreign  bodies  may  remain  for  a  length  of  time  suspended 
in  the  vitreous  humour  without  doing  much  harm,  or  may  become 
surrounded  by  lymph,  and  thus  encysted  or  encapsuled,  yet  this  is  only 
of  very  exceptional  and  rare  occurrence,  more  particularly  if  they  are 
considerable  in  size,  and  of  a  nature  to  set  uj?  irritation  by  undergoing 

*  Vide  Arlt's  "  Bericlit  der  Wiener  Augenklinik,"  1867. 

2  F  2 


4ofi  DISEASES   OF   THE   CHOROID. 

chemical  changes.  Inflammation  of  the  vitreous  hiimotir  supervenes, 
extending  to  the  retina  and  choroid,  and  the  eye  becomes  destroyed 
by  plastic  irido- choroiditis,  or  suppurative  panophthalmitis. 

It  may  also  ensue  upon  operations,  such  as  those  for  the  removal  of 
cataract,  either  by  extraction,  or  still  more  frequently  after  couching 
(vide  the  article  upon  Cataract).  It  occurs  most  frequently  in  old  and 
decrepid  individuals,  or  in  instances  in  which  the  patients  are  exposed 
after  the  operation  to  bad  ventilation,  over-crowded  rooms,  or  other 
infl-uences  which  impair  the  purity  of  the  air  (pyaemia  in  a  hospital, 
typhoid  fever,  etc.).  It  is  an  interesting  and  important  fact,  that 
eyes  operated  upon  for  chronic  irido-choroiditis  show  very  little  ten- 
dency indeed  to  take  on  suppurative  inflammation,  even  although  the 
lens  may  have  been  removed,  together  with  a  portion  of  the  iris  and 
dense  masses  of  exudation.  Indeed,  such  eyes  bear  a  great  deal  of 
operative  interference  with  impunity. 

Suppurative  inflammation  of  the  cornea  and  iris  (as  for  instance  in 
purulent  and  diphtheritic  ophthalmia)  may  also  be  followed  by  panoph- 
thalmitis. 

It  may  likewise  be  produced  by  a  direct  extension  of  the  inflamma- 
tion from  the  meninges  to  the  eye,  as  in  cases  of  typhus,  cerebro- spinal 
meningitis,  etc. ;  but  it  may  also  in  such  instances  be  dtie  to  metastasis, 
examples  of  which  are  not  unfrequently  seen  in  puerperal  fever.  A 
very  short  time  after  the  occurrence  of  the  embolism  suffices  to  set  up 
secondary  metastatic  foci  of  disease  in  even  distant  organs.  According 
to  0.  Weber,*  two  days  will  suffice  for  this.  This  metastatic  form  of  the 
disease  may  either  assume  a  very  severe  and  acutely  inflammatory  type, 
rapidly  leading  to  suppurative  disorganization  of  the  globe ;  or  it  may 
run  a  more  insidious  but  equally  destructive  course.  It  is  chiefly  met 
with  in  cerebro-spinal  meningitis,  puerperal  fever,  and  pyaemia ;  and 
then  almost  invariably  attacks  both  eyes.f  It  is  a  question  whether  it 
may  not,  in  cerebro-spinal  meningitis,  be  sometimes  due  to  the  exposure  of 
the  cornea  to  traumatic  injuries,  on  account  of  the  great  lagophthalmos. 

The  prognosis  is  most  iinfavourable,  for  this  is  one  of  the  most 
destructive  and  intractable  diseases  of  the  eye.  It  is  but  seldom  that 
we  can  arrest  its  progress  in  time  to  save  any  useful  degree  of  sight. 
In  most  cases  it  soon  ends  in  atrophy  of  the  eyeball,  either  with  or 
without  a  previous  perforation  of  the  cornea  or  sclerotic  and  escape  of 
some  of  the  contents  of  the  eye.  The  dangerous  nature  of  the  disease 
is  especially  terrible  in  cases  of  metastatic  choroiditis,  for  instance  in 
puerperal  fever,  or  cerebro-spinal  meningitis,  as  both  eyes  are  generally 

*  Billroth,  "Handbuch  der  Chirurgic." 

+  Vide  Dr.  Knapp's  article  on  Metastatic  Choroiditis,  "  Archiv.  f.  O.,"  xiii,  1, 
127  ;  also  Dr.  Wilson's  paper  on  "  Diseases  of  the  Eye  in  Cerebro-spinal  Meningitis," 
"Dub.  Quart.  Journ.,"  May,  1867. 


SUPPURATIVE   CHOROIDITIS.  437 

affected,  and  then,  if  tlie  patient  should  survive,  it  will  be  only  to  pass 
his  days  in  utter  blindness.  But  in  some  cases,  the  danger  is  not 
confined  to  the  loss  of  sight,  for  even  life  may  become  imperilled,  as 
Von  Grraefe  has  shown,  by  the  extension  of  the  suppui-ative  inflamma- 
tion to  the  brain,  there  setting  up  suppurative  meningitis,  which  may 
prove  fatal. 

After  perforation  of  the  cornea  or  sclerotic  has  taken  place,  the 
intense  pain  and  inflammatory  symptoms  generally  at  once  subside  to  a 
very  considerable  degree.  The  eye  diminishes  in  size  and  gradually 
becomes  shrivelled  up  and  changed  into  a  small  contracted  stump, 
wliich,  as  a  rule,  does  not  remain  painful,  and  is  not  prone  to  give  rise 
to  sympathetic  ophthalmia,  except  indeed  it  contains  a  foreign  body, 
which  keeps  up  a  considerable  degree  of  irritation,  and  is  always  a 
soui'ce  of  danger  to  the  other  eye.  Sometimes,  however,  the  eye  retains 
a  certain  size  and  consistence,  not  becoming  completely  atrophied,  and, 
on  the  aqueous  and  vitreous  humour  becoming  more  transparent, 
we  may  be  able  to  examine  them  with  the  ophthalmoscope,  and  find 
that  fresh  masses  of  exudation  are  effused  ;  the  lens  subsequently 
becoming  opaque. 

The  treatment  must  in  the  first  place  be  directed  to  saving,  if  pos- 
sible, some  remnant  of  sight,  and  then  if  this  be  out  of  the  question, 
to  mitigating  the  great  sufferings  of  the  patient.  Thus,  if  it  be  pro- 
diiced  by  a  foreign  body  which  it  is  possible  to  seize  and  extract,  this 
should  be  done  without  loss  of  time,  even  although  it  may  be  necessary 
to  pass  the  instrument  into  the  vitreous  humour  (vide  article  upon 
The  Presence  of  Foreign  Bodies  in  the  Vitreous  Humour).  If  the 
lens  is  injured  and  swollen,  it  should  be  at  once  removed  together  with 
a  considerable  portion  of  the  iris,  if  symptoms  of  severe  inflammation 
supervene. 

If  there  is  a  perforating  ulcer  of  the  cornea  with  hypopyon,  either 
paracentesis  (perhaps  frequently  repeated)  or  iridectomy  should  be 
performed. 

If  a  Im-eign  body  has  entered  the  vitreous  humour  and  lies  beyond 
our  reach,  and  if  it  be  small  and  has  not  injured  the  lens  or  committed 
any  considerable  mischief  in  its  course,  we  must  endeavour  by  the 
strictest  antiphlogistic  treatment  to  subdue  the  inflammatory  complica- 
tions, and  if  possible  to  prevent  suppurative  choroiditis.  Indeed  in 
some  of  these  cases,  the  foreign  body  becomes  encapsuled  and  remains 
inocuous,  an  excellent  degree  of  vision  being  perhaps  restored.  But 
when  a  foreign  body  remains  in  the  eye,  we  must  always  keep  in  mind 
the  great  danger  of  sympathetic  ophthalmia.  If  the  eye  is  hope- 
lessly destroyed  by  the  accident,  it  will  be  by  far  the  wisest  and  safest 
course  to  remove  it  at  once,  so  as  not  only  to  avoid  all  danger  of  sympa- 
thetic ophthalmia,  but  also  the  occurrence  of  suppurative  choroiditis. 


438  DISEASES   OF  THE   CHOROID. 

For  when  symptoms  of  panophthalmitis  have  supervened,  it  will  be  no 
longer  safe  to  do  so,  because  there  is  imminent  risk  of  the  suppuration 
extending  to  the  brain  and  producing  fatal  suppurative  meningitis. 
Cases,  in  which  this  has  occui-red  after  excision  of  the  eyeball  during 
acute  panophthalmitis,  have  been  recorded  by  Von  Graefe,  Knapp, 
Manhardt,  etc.* 

If  the  inflammatory  symptoms  are  very  severe,  and  of  a  sthenic 
character,  cold  compresses  (iced)  should  be  constantly  applied  as  long 
as  they  prove  agreeable  to  the  patient.  Leeches  should  be  placed  on 
the  temple,  and  if  the  patient  is  strong  and  the  suppuration  has  not 
already  become  too  extensive,  so  as  to  afford  little  or  no  chance  of 
arresting  it,  rapid  salivation  should  be  induced,  in  the  hopes  of  checking 
the  inflammation  and  preserving  some  degree  of  sight.  Generally, 
however,  this  proves  futile.  The  severe  pain  in  and  around  the  eye  is 
often  most  relieved  by  hot  poppy  fomentations  or  poultices,  and  by  the 
subcutaneous  injection  of  morphia  at  the  temple.  If  there  is  hypopyon, 
or  the  tension  of  the  eye  is  much  increased,  paracentesis  of  the  anterior 
chamber  should  be  performed,  and  repeated  at  intervals  of  a  day  or 
two,  or  even  less.  If  the  eye  is  very  distended  and  causes  great 
suffering  to  the  patient,  the  paracentesis  may  be  made  into  the  vitreous 
humour  instead,  which  often  affords  great  relief. 

The  patient's  strength  must  be  sustained  by  very  nourishing  diet, 
the  free  use  of  stimulants,  and  by  the  administration  of  tonics. 

If  the  pain  and  inflammation  are  very  severe  and  protracted,  and  so 
greatly  enfeeble  the  patient  as  even  to  endanger  life,  it  will  be  best  to 
remove  the  eye  at  all  hazards,  even  at  the  risk  of  an  extension  of  the 
disease  to  the  brain,  in  order  at  once  to  remove  all  source  of  pain,  and 
thus  enable  the  patient  to  regain  his  strength. 

Kjiappt  has  lately  described  two  very  interesting  cases  of  embolism 
of  the  choroidal  vessels.  In  each  patient  there  existed  well  marked 
cardiac  disease  (in  the  one  endo- carditis,  in  the  other  insufficiency  and 
stenosis  of  the  aortic  valves  with  hypertrophy  of  the  left  ventricle). 
The  affection  of  the  sight  was  quite  sudden,  the  patients  noticing  a 
dark  cloud  before  the  eye,  which  at  first  pervaded  the  whole  visual 
field,  but  then  became  concentrated  in  the  central  portion.  The  impair- 
ment of  vision  does  not  occur  with  such  great  suddenness  as  in  embo- 
lism of  the  central  artery  of  the  retina,  nor  to  such  an  extent,  for  in 
the  one  case  V  :=  -^,  in  the  other,  the  patient  could  read  the  finest  print, 
and  only  noticed  a  large  scotoma  lying  near  the  axis  of  vision.  There 
were  marked  chromopsy  and  photopsy.  The  ophthalmoscope  revealed 
a  circumsci'ibed  cloud  or  veil  in  the  central  portion  of  the  fundus  (and 

•  "Kl.  Monatsblat.,"  1863,  p.  456. 
t  "A.  f.  O.,"  xiv,  1. 


COLLOID   DISEASE   OF   THE   CHOROID.  439 

corresponding  to  the  scotoma),  which  was  due  to  a  serous  effusion 
into  the  retina  which  extended  to  the  disc.  The  vessels  were  also 
hyperaemic  in  this  clouded  portion  of  the  retina.  These  conditions 
were  evidently  those  of  collateral  eflfusion  and  hypersemia,  and  due  to 
embolism  of  some  of  the  choroidal  vessels  at  this  point.  These 
phenomena  are  easily  explained  when  we  remember  the  anastomosis 
between  the  central  artery  of  the  retina  and  those  ciliary  arteries  which 
perforate  the  sclerotic  in  the  vicinity  of  the  disc.  The  patients  sub- 
sequently quite  regained  their  sight,  and  the  fundus  resumed  its  normal 
appearance. 

5.— COLLOID  DISEASE  OF  THE  CHOROID. 

This  affection  Avas  first  described  by  Wedl,*  and  consists  in  the 
formation  of  peculiar,  transparent,  bead-like  globules  on  the  inner 
surface  of  the  choroid.  Dondersf  supposed  them  to  be  due  to  senile 
changes,  dependent  upon  a  colloid  metamorphosis  of  the  nuclei  of  the 
hexagonal  pigment  cells,  whereas  H.  MiillerJ  thought  that  these  little 
bodies  lie  horizontally  behind  the  pigment  cells,  and  are  due  to  an  adven- 
titious thickening  of  the  elastic  lamina.  From  the  researches  of 
Mr.  Hulke,  the  latter  view  appears  to  be  the  true  one  ;§  he  moreover 
found  that  the  capillary  vessels  of  the  choroid  do  not  appear  to  be 
primarily  affected,  as  the  blood  corpuscles  could  be  distinctly"  seen 
gliding  along  the  capillary  vessels  in  unbroken  column  heneath  the 
globules,  i.e.,  to  the  outer  side  of  them. 

The  colloid  globules  are  highly  refracting,  and  are  arranged  singly, 
or  in  little  groups  or  clusters.  They  assume  various  shapes,  being 
globular,  oval,  or  club-shaped.  They  are  but  slightly,  if  at  all  affected 
by  reagents.  Their  size  varies  from  -^-^-50  ^^  a\o  ^^  ^^  inch  (Hulke). 
They  are  very  apt  to  undergo  chalky  and  fatty  degeneration,  and  then 
present  a  finely  granular  appearance. 

On  account  of  the  colloid  masses  pushing  aside,  or  even  destroying 
the  hexagonal  pigment  cells,  the  latter  are  crowded  together,  so  as  to 
form  a  narrow,  dark  rim  or  fringe  around  the  single  or  aggregated 
globules.  Hence,  the  choroidal  epithelium  presents  here  and  there  a 
somewhat  variegated,  patchy  appearance.  Indeed  this  is  about  the 
only  sign  by  which  the  presence  of  colloid  disease  of  the  choroid  can 
be  recognised  with  the  ophthalmoscope.  Wenotice||  small,  faintly  pig- 
mented pale  patches,  surrounded  by  a  dark  fringe  of  pigment  cells, 
the  choroidal  vessels  being  hidden  by  the  chalky  deposits.  These 
patches  may  be  strewn  about  at  small  intervals  over  a  considerable  por- 
tion of  the  choroid,  more  especially  towards  the  equator  of  the  fundus. 

*  "  G-rundziige  der  Histologic,"  1854. 

t  "A.  f.  O.,"  i,  2,  107.  X  Ibid.,  ii,  2,  1. 

§  "  B.  L.  O.  H.  Rep.,"  i,  pp.  70  and  180.       |1  Liebreich,  "  A.  f.  O.,"  iv,  2,  290. 


440  DISEASES  OF   THE   CHOROID. 

It  was  supposed  that  these  colloid  formations  were  due  to  some 
senile  changes,  as  they  are  most  frequently  met  with  in  old  persons. 
But  Hulke*  has  seen  them  also  occur  in  quite  young  individuals,  and 
considers  that  inflammation  is  the  cause  of  these  adventitious  thickenings 
of  the  elastic  lamina,  as  he  has  frequently  found  colloid  disease  asso- 
ciated with  inflammatory  changes.  He  states  that  it  is  almost  always 
present  in  shrunken  globes  which  have  been  repeatedly  inflamed, 
and  he  has  also  seen  it  several  times  in  acute  traumatic  inflam- 
mation. 

On  account  of  the  atrophy  of  the  choroidal  epithelium,  and  con- 
sequent injury  to  the  rods  and  bulbs  of  the  retina,  the  sight  is  often 
much  impaired  at  an  advanced  stage  of  the  disease,  and  if  the  latter 
has  invaded  the  posterior  pole  of  the  eye.  Fortunately,  however,  it 
frequently  remains  confined  to  the  periphery  of  the  fundus  (the 
vicinity  of  the  ora  serrata),  and  then  of  course  only  the  outline  of  the 
visual  field  will  be  aff"ected. 


6.— TUBERCLES  OF  THE  CHOROID. 

It  was  formerly  supposed  by  some  surgeons  that  a  peculiar  form  of 
plastic  choroiditis  was  sometimes  met  with  in  the  later  stages  of  chronic 
tuberculosis,  and  was  consequently  termed  "  tubercular  choroiditis." 
The  extensive  and  very  careful  researches  of  Cohnheim  have  shown, 
however,  that  this  is  not  the  case,  for  he  has  failed  to  detect  the  pre- 
sence of  tubercular  deposits  in  the  choroid  in  any  case  of  localised 
tuberculosis  of  the  lungs  or  intestines. f  Manz,J  however,  discovei'ed 
anatomically  in  three  instances,  the  important  and  interesting  fact  of 
the  presence  of  tubercles  in  the  choroid  in  acute  miliary  tuberculosis. 
Bush§  subsequently  narrated  another  case.  On  account  of  the  paucity 
of  these  instances,  it  was  generally  supposed  that  the  co-existence  of 
tubercles  in  the  choroid  with  acute  miliary  tuberculosis  was  very  rare 
and  exceptional.  The  great  error  of  this  supposition  has,  however, 
been  shown  by  Cohnheim,  who  found  in  18  cases  of  miliary  tubercu- 
losis (which  underwent  post  mortem  examination  in  the  Berlin  Patho- 
logical Institution)  tubercles  in  the  choroid  of  one  or  both  eyes  in  every 
■instance.  Whilst  their  presence  was  thus  proved  anatomically,  it  was 
reserved  fur  Von  Graefe||  to  make  the  first  ophthalmoscopic  diagnosis 
of  the  disease. 

With  the  ophtbalmoscope,  tubercles  in  the  choroid  appear  in  the 
form  of  small  circidar,  cu-cumscribed  spots   of  a   pale  rose-colour,  or 

*  "  R.  L.  O.  11.  Rep.,"  i,  181.  t  "  A.  f.  O.,"  xiv,  1,  188,  note. 

X  lb.,  iv,  2,  120,  and  ix,  3,  133.  §  Virchow's  "  Avchiv.,"  vol.  36,  p.  448. 

II  "A.  f.  O.,"  xiv,  1,  193. 


TUBERCLES  OF  THE  CHOROID.  441 

grejish-white  tint,  and  vary  in  size  from  i  to  2'5  mm.  They  are  chiefly 
situated  in  the  vicinity  of  the  optic  disc,  but  may  extend  occasionally 
to  a  considerable  distance  from  it.  Although  the  smaller  tubercles 
only  produce  a  stretching  or  widening- up  of  the  choroidal  epithelium, 
without  any  loss  of  the  pigment  molecules,  and  hence  only  give 
rise  to  a  moderate  discoloration  of  the  choroid  at  this  spot  (Graefe), 
yet  they  should  not  escape  the  detection  of  a  careful  and  dexterous 
ophthalmoscopist,  more  especially  if  they  are  situated  near  the  centre  of 
the  fundus.  If  they  occui'  near  the  equator  it  may  be  different,  more 
especially  as  these  patients  are  often  difficult  to  examine  on  account  of 
then"  restless  or  comatose  condition.  The  larger  nodules  give  rise  to 
more  marked  changes,  and  are  distinctly  elevated  above  the  level  of 
the  choroid,  as  is  evidenced  by  the  parallax  which  can  be  noticed  if  a 
retinal  vessel  is  found  to  pass  over  one  of  these  nodules.  The  choroid 
around  the  latter  is  quite  normal,  and  there  is,  except  in  very  few  cases, 
no  collection  of  pigment  around  them,  although  at  their  margin  there  is 
a  feint  red  zone,  by  which  the  paler  red  or  greyish  central  portion 
gradually  passes  over  into  the  normally  tinted  choroid.  Together  with 
these  changes  in  the  choroid,  there  may  exist  more  or  less  marked 
hyperaemia  of  the  retina,  but  there  is  not  the  least  trace  of  any  loss  of 
transparency  of  the  latter,  even  in  the  vicinity  of  the  dilated  vessels. 
The  number  of  the  tubercles  may  vary  from  1  to  52  (Cohnheim). 

Although  there  is  no  doubt  that  the  tubercles  are  formed  in  the 
stroma  of  the  choroid,  their  exact  mode  of  development  is  yet  uncer- 
tain. Thus  Manz  supposed  that  they  originated  primarily  in  the 
tunica  adventitia  of  the  larger  choroidal  vessels ;  Bush  thought  that 
they  were  formed  from  the  colourless  cells  of  the  stroma  of  the 
choroid ;  whereas,  Cohnheim  considers  that  they  are  developed  from 
peculiar  cells  (Wanderzellen)  resembling  lymph  corpuscles,  which  lie 
strewn  about  in  the  choroid. 

Soon  after  the  publication  of  Cohnheim's  paper,  I  was  fortunate 
enough  to  diagnose,  with  the  ophthalmoscope,  the  presence  of  tubercles 
in  the  choroid,  and  submitted  the  preparation  to  the  Pathological 
Society  at  the  commencement  of  this  year. 

As  this  is  the  first  case  in  which  tubercles  of  the  choroid  have  been 
met  with  in  England,  and  as  it  illustrates  well  their  ophthalmoscopic 
characteristics,  I  give  it  in  extenso. 

M.  J.  P.,  a  little  girl  aet.  8,  was  admitted  on  November  5th,  1867, 
into  King's  College  Hospital  under  the  care  of  Dr.  Garrod,  with  symp- 
toms of  acute  tuberculosis.  She  had  become  rapidly  emaciated  during 
the  last  month,  and  had  during  that  time  suffered  from  dypsnoea  and 
dry  cough.  On  admission  there  was  great  febrile  disturbance,  pulse 
132,  respu-ations  66,  temperature  101°.  Slight  dulness  of  left  side  of 
chest,  and  crepitation  about  the  second  intercostal  space.     November 


442  DISEASES  OF   THE   CHOROID. 

6t]i. — Temperature  106°,  pulse  148,  respiration  96.  Urine  acid,  no 
albumen.  Puerile  respiration  on  right  side,  slightly  tubular  on  left. 
I  examined  the  eyes  with  the  ophthalmoscope,  and  diagnosed  the  pre- 
sence of  tubercles  in  the  choroid.  November  11th. — The  patient  grew 
rapidly  worse  and  died  on  this  day. 

Post  moi'tem  examination  by  Dr.  Kelly. 

The  brain  substance  was  apparently  normal,  but  on  the  superior 
aspect  of  the  left  hemisphere  were  seen  two  or  three  small  opacities  in 
the  pia  mater.  Both  lungs  were  filled  with  miliary  tubercle.  Liver 
and  heart  healthy,  kidneys  contained  tubercles  in  their  cortical  sub- 
stance and  were  throughout  congested.  Capsule  of  spleen  had  some 
tubercular  (?)  deposits,  the  organ  itself  being  healthy.  The  mesenteric 
glands  were  somewhat  increased  in  size  and  number,  and  some  solitary 
glands  of  the  small  intestines  were  enlarged.  The  surface  of  the  peri- 
toneum was  healthy. 

Examination  of  the  eyes  during  life. 

I  found  that  the  eyes  appeared  externally  quite  normal.  The  sight 
was  perfect  (No.  1  Jaeger).  The  field  of  vision  normal.  The  refracting 
media  perfectly  transparent.  With  the  ophthalmoscope,  it  was  found 
that  the  optic  nerve  and  retina  were  healthy,  the  retinal  veins  slightly 
dilated  ;  the  outline  of  the  disc  perfect.  In  the  choroid — which  was 
otherwise  perfectly  norraal — were  noticed  numerotis  small,  circular,  pro- 
minent, greyish- white  nodules,  which  were  chiefly  situated  in  the  vicinity 
of  the  optic  disc,  more  especially  in  the  region  of  the  yellow  spot. 
Towards  the  periphery  of  the  fundus  they  were  more  sparsely  scattered. 
The  epithelium  of  the  choroid  around  the  nodules  was  only  very  slightly 
altered  in  appearance,  the  cells  being  evidently  opened  up  or  pushed 
aside  by  the  nodules,  and  there  was  no  agglomeration  of  pigment 
around  the  latter,  but  the  thinned  portion  of  the  epithelium  passed 
insensibly  over  into  the  normal  condition.  At  some  points,  a  nodule 
could  be  seen  lying  beneath  a  retinal  vessel  which  passed  distinctly 
over  it.  The  nodules  were  prominent,  but  whether  or  not  the  retinal 
vessel  was  arched  forward  by  the  tubercle  could  not  be  accurately 
determined,  as  it  was  quite  impossible  to  distinguish  with  certainty  as 
to  the  presence  of  a  parallax,  on  account  of  the  restless  movements  of 
the  patient's  eye.     The  condition  was  very  similar  in  both  eyes. 

The  diagnosis  of  tubercular  deposits  in  the  choroid  was  verified  by 
a  careful  dissection  made  by  Mr.  Bowater  Vernon,  the  curator  of  the 
Moorfields  Hospital,  an  account  of  which  will  be  found  in  the  "R.  L.  0.  H. 
Reports,"  vi,  2,  163. 

Other  interesting  facts  in  connection  with  this  subject  are,  that 
Cohnhoim  found  that  the  thyroid  gland,  which  was  supposed  to  enjoy  a 
special  immunity  from  tubercular  deposits,  was  in  most  cases  implicated. 


SARCOMA   OF   THE   CHOROID.  443 

He  has,  moreover,  succeeded,  in  guinea-pigs,  in  producing  tubercles  in 
the  choroid  by  inoculation.  The  matter  was  taken  from  a  tuberculous 
lymphatic  gland,  arid  the  animal  died  five  weeks  after  the  inoculation, 
when,  besides  those  in  the  choroid,  miliary  tubercles  were  met  with  in 
all  the  organs,  viz.,  in  the  lungs,  liver,  kidneys,  spleen,  serous  mem- 
branes, etc.* 

7.— TUMOURS  OF  THE  CHOROID. 

We  meet  with  two  forms  of  tumour  in  the  choroid — 1.  sarcoma; 
2.  carcinoma  or  cancer  ;  the  latter  being  again  subdivided  into  medul- 
lary and  melanotic  carcinoma.  But  in  many  instances  the  tumour  pre- 
sents a  mixed  character,  being  partly  sarcomatous  and  partly  carcino- 
matous. According  to  Von  Graefe,t  the  great  majority  of  choroidal 
tumours  are  of  a  sarcomatous  natui'e  ;  a  much  smaller  proportion  are  of  a 
mixed  character ;  and  only  in  exceptional  instances  are  they  carcino- 
matous. These  differences  in  the  nature  of  the  tumour  are,  however, 
only  recognisable  with  the  microscope,  as  the  eye  does  not  present  any 
special  symptoms  which  would  enable  us  to  decide,  whether  or  not  a 
given  case  of  iutra-ocular  tumour  is  of  a  sarcomatous  or  carcinomatous 
nature. 

(1.)— SARCOMA  OF  THE  CHOROID. 

The  disease  presents  itself  at  the  outset,  as  a  small  nodule  in  the 
posterior  or  lateral  portion  of  the  choroid,  being  developed  from  the 
pigmented  connective  tissue  of  the  latter.  During  the  earliest  stage, 
the  choroidal  epithelium  and  the  retina  may  remain  iinaffected,  passing 
intact  over  the  little  nodule.  But  as  the  latter  increases  in  size,  the 
retina  generally  becomes  more  or  less  detached  by  the  effusion  of  a 
serous  or  hgemorrhagic  reddish-brown  fluid,  which  causes  the  detached 
portion  of  the  retina  to  fluctuate  and  tremble  on  every  movement  of  the 
eye.  Subsequently,  the  retina  mostly  becomes  completely  detached  (the 
vitreous  humour  undergoing  a  corresponding  diminution  in  volume), 
giving  rise  to  the  well-known  funnel- sh a j)ed  detachment,  the  apex  of 
which  is  situated  at  the  optic  nerve,  the  base  at  the  ora  serrata ;  the 
space  external  to  the  detached  retina  being  occupied  by  the  tumour, 
and  more  or  less  fluid.  The  lens  now  soon  becomes  cataractous,  if  this 
has  not  already  occurred,  more  especially  at  its  posterior  pole.  The 
vitreous  humour  may  lose  its  transparency  at  an  earlier  stage  of  the 
disease,  whilst  the  detachment  is  still  but  partial,  so  that  the  details  of 

*  "A.  f.  O.,"  xiv,  1,  205. 

t  "A.  f.  O.,"  xiv,  2,  115.  The  reader  ■will  fiucl  iu  tliis  article  a  very  interesting 
and  valuable  account  of  the  chief  differences  between  the  symptoms,  development, 
and  course  of  sarcoma  of  the  choroid  and  glioma  retinae. 


444  DISEASES   OP   THE   CHOROID. 

the  fundus  are  perhaps  obscured  by  a  diffuse  haziness  of  the  vitreous, 
intermixed  with  more  or  less  filiform  or  membranous  opacities.     If  the 
retina    retains  its  transparency   and   lies   in   close   contact  with    the 
tumour,  it  may  be  possible,  in  some  cases,  to  recognise  the  latter  with 
the  ophthalmoscope,  as  it  presents  the  appearance  of  a  distinct,  smooth, 
or  slightly  nodulated  swelling,  the  colour  of  which  may  vary  from  a 
pale  brown  to  a  dark  coffee- col  cured  tint,  according  to  the  amount  of 
pigment  which    it   contains.     If  the  detached  retina  should  undergo 
inflammatory  or  fatty  changes   and  become  thickened,  a  yellow  reflex 
may  take  the  place  of  the  brown  colour  of  the  tumour.     But  this  reflex 
differs  from  that  met  with  in  glioma,  by  not  being  of  so  brilliantly 
white  or  whitish-yellow  a  tint,  or  so  brightly  opalescent  (Yon  Graefe).* 
As  a  rule,  the  early  stage  of  the  disease  is  accompanied  by  a  serous 
detachment  of  the  retina,  which  will  completely  hide  the  presence  of  the 
tumour ;  and  it  is  only  when  the  latter  increases  in  size  and  reaches  up 
close  to  the  detached  retina,  that  small,  dark,  knob-like  protuberances 
may  appear  beneath  the  latter,  side  by  side,  perhaps,  with  portions  of 
detached  retina,  which  show  a  distinct  tremulousness  when  the  eye  is 
raoved.     I  have  already  (p.  358)   called  special  attention  to  the  fact 
that  the    degree    of    the   intra-ocular   tension   is    of  great    diagnostic 
importance  in  cases  of  detachment  of  the  retina  ;  for  whilst  it  is,  as  a 
rule,  diminished  in  cases  of  simple  detachment,  it  either  remains  normal 
or  is  more  or  less  increased  when  the  latter  is  due  to  the  presence  of  an 
intra-ocular  tumour.     Indeed,  in  the  more  advanced  stages  of  sarcoma, 
the  disease  often  assumes  marked  glaucomatous  symptoms.     The  ten- 
sion   of    the   eye   is    greatly   increased,    the    cornea   perhaps   steamy, 
roughened,  and  anaesthetic,  the  anterior  chamber  very  shallow,  the  iris 
pushed    forward    and  its    tissue    atrophied,    the   pupil   dilated    (often 
irregularly),  the  lens  perhaps  opaque,  the  sight  lost.    The  patient  com- 
plains of   great  ciliary  neuralgia,   extending,   may  be,  to   the    corre- 
sponding side  of  the  head  and  face.     The  sufferings  are  especially  acute 
and  sudden  if  intra-ocular  haemorrhage  has  occurred.     At  a  later  date 
staphylomatous  bulgings  may  appear  in  the  ciliary  region,   and  might 
be  mistaken  for  masses  of  tumour ;  theii'  transparency,  when  a  strong 
light  is  thrown  upon  them  will,  however,  guard  us  against  such  an  error 
(Graefe).     After  the  increased  tension  has  existed  for  some  length  of 
time,  a  severe  attack  of  acute  glaucomatous  inflammation  may  super- 
vene.    Von  Graefe  calls  attention  to  the  fact,  that  he  has  several  times 
noticed  this  occurrence  after  atropine  had  been  applied  for  the  purpose 
of  facilitating  the  ophthalmoscoping  examination.     Now  if  we  do  not 
know  the  history  of   the  case   (the  prior  detachment  of  the  retina, 
etc.)  and  the  media  are  too  clouded  to  permit  of  an  ophthalmoscopic 
examination,  it  may   be   very  difficult  to  recognise  the   true  nature  of 
*    "A.  f.  O.,"  xiv,  2,  109. 


SARCOMA   OF   THE   CHOROID.  445 

the  disease,  and  it  will  be  perhaps  considered  a  simple  case  of  glau- 
coma. An  iridectomy  is  made,  and  the  pain  temporarily  relieved  by  the 
diminution  of  the  tension.  But  it  soon  recurs  with  all  its  former 
violence,  the  eye  again  becomes  hard,  our  suspicions  are  aroused  as  to 
the  presence  of  an  intra-ocular  tvimour,  the  eyeball  is  enucleated,  and  our 
conjectures  are  verified.  This  fact  has  led  some  sui-geons  to  the  belief 
that  melanotic  sarcoma  is  very  prone  to  become  developed  in  glauco- 
matous eyes.  But  this  does  not  appear  to  be  the  case,  the  glauco- 
matous condition  being  simply  one  phase  of  the  disease.  Such  cases  of 
supposed  glaucoma  in  which  intra-ocular  tumours  were  subsequently 
found,  have  been  observed  by  Bowman,*  Graefe,t  Hutchinson,J 
Dor,§  etc. 

Sometimes,  however,  the  presence  of  the  tumour  sets  up  great  irrita- 
tion, and  finally  gives  rise  to  a  plastic  form  of  irido-choroiditis,  which  leads 
to  a  more  or  less  considerable  temporary  atrophy  of  the  eyeball.  The 
shrunken  globe  becomes  the  seat  of  intense,  persistent  pain,  for  the 
relief  of  which  enucleation  is  performed,  and  then  the  tumour,  the  real 
source  of  the  mischief,  is  discovered.  It  must  be  mentioned,  however, 
that  whilst  temporary  atrophy  of  the  globe  is  not  unfrequently  observed 
in  the  course  of  glioma  retina?,  this  is  only  exceptionally  the  case  in 
sarcoma  of  the  choroid  ;  as  the  choroidal  inflammation  generally  assumes 
a  secretory  or  serous-htemorrhagic  character,  indeed  the  glaucomatous 
condition  may  even  continue  after  the  extra-ocular  development  of  the 
disease.  The  atrophy  generally  depends  upon  sloughing  of  the  cornea  from 
paralysis  of  the  corneal  nerves,  which  is  followed  by  more  or  less  severe 
suppurative  panophthalmitis  (Von  Graefe).  ||  Attention  has  been  called 
by  Von  Graefe^y  to  several  points  which  may  enable  us  to  distinguish 
between  simple  atrophy  of  the  eyeball,  and  that  which  is  dependent 
upon  intra-ocular  sarcoma.  In  the  latter  case,  very  severe  spontaneous 
paroxysms  of  pain  occur,  whilst  the  ciliary  region  is  hardly,  if  at  all, 
sensitive  to  the  touch ;  whereas,  in  the  atrophy  ensuing  upon  irido- 
cyclitis, the  reverse  obtains,  there  being  but  little,  if  any,  spontaneous 
pain,  but  the  eye  remaining  for  a  long  time  sensitive  to  the  touch. 
Moreover,  if  a  sarcoma  is  present  in  the  atrophied  globe,  the  diminution 
in  size,  or  flattening  of  the  eyeball,  occurs  in  the  antero-posterior  axis, 
the  equatorial  region  not  contracting  to  the  same  extent.  The  depres- 
sions caused  by  the  four  recti  muscles  are,  therefore,  unusually  apparent 
upon  the  anterior  surface  of  the  globe.  Again,  on  account  of  the  sub- 
sequent contraction  of  the  connective  tissue  elements,  which  have  been 
formed  within  the  eye  in  the  course  of  the  panophthalmitis,  a  barrier  is, 
to  a  certain  extent,  placed  against  the  development  of  the  tumour  in 


*  ' 

"R.  L.  0.  H.  Rep.,"iv,  81. 

t  "A.  f.  0.; 

'  X,  1,  179, 

t ' 

"R.  L.  0.  H.  Rep.,"  v,  88. 

§  "  A.  f.  0.,' 

"  vi,  2. 

il ' 

'  A.  f.  0.,"  xiv,  2,  120. 

IF  lb. 

446  DISEASES   OF   THE   CHOROID. 

front.  Hence,  althongli  the  latter  increases  in  size,  the  collapsed  eyeball 
does  not  fill  out  and  become  plumper,  but  remains  flattened,  and  a 
retro-ocular  extension  of  the  morbid  growth  occurs,  pushing  the  eyeball 
forward,  and  thus  causing  a  certain  degree  of  exophthalmos.  In  esti- 
mating the  degree  of  the  latter,  we  must  not  forget  that  the  eyeball  is 
diminished  in  size,  otherwise,  we  may  easily  undervalue  the  extent  of 
the  protrusion. 

The  progress  of  sarcoma  of  the  choroid  is  generally  slow  as  long  as 
it  is  confined  by  the  firm  sclerotic  within  the  cavity  of  the  eye,  and  it 
may  remain  stationary  for  a  considerable  length  of  time  ;  but  if  it  has 
once  perforated  the  coats  of  the  eyeball,  its  progress  is  very  rapid. 
Its  exposed  surface  becomes  ulcerated,  and  covered  by  a  dark  red  crust 
of  blood  and  ichorous  discharge,  upon  the  laceration  of  which  it  bleeds 
freely,  often  very  profusely.  Perforation  may  take  place  at  the  cornea 
(generally  at  or  near  the  sclero-corneal  junction),  at  the  front  part  of 
the  sclerotic,  or  at  its  posterior  portion,  close  to  the  optic  nerve.  The 
disease  may  also  extend  into  the  optic  nerve  ;  small,  dark,  stringy  patches 
being  found  to  pass  backwards  from  the  lamina  cribrosa  between  the 
nerve  tiibules,  and  thus  causing  an  extension  of  the  disease  into  the 
orbit,  or  towards  the  brain.  With  regard  to  the  implication  of  the  optic 
nerve.  Von  Graefe  is  of  opinion  that  the  disease  at  the  outset  extends 
fr-om  the  lamina  cribrosa  along  the  inner  sui'face  of  the  nerve- 
sheath,  or  along  the  septa  of  the  perineurium.  Whereas  in  glioma,  the 
whole  thickness  of  the  nerve  is  simultaneously  aff'ected.  Or  again 
small,  circumscribed,  black  patches  make  their  appearance  on  the  scle- 
rotic, being  apparently  independent  of  the  disease,  and  their  pre- 
sence is  generally  prognostic  of  a  rapid  extension  of  the  tumour. 
According  to  Virchow,  the  microscope,  as  a  rule,  reveals  a  progressive 
implication  of  the  sclerotic. 

The  appearance  which  the  tumour  presents  on  section,  varies  with 
the  amount  of  pigment  which  it  contains.  It  is  generally  marbled  or 
speckled,  some  portions  being  pale,  others  of  a  more  or  less  deep  brown 
tint.  These  melanotic-sarcomatous  tumours  may,  however,  be  of  a 
uniform,  black,  inky  colour.  But  according  to  Virchow*  sarcoma  of  the 
choroid  may,  in  very  exceptional  cases,  be  quite  colourless,  and  this  is 
probably  due  to  some  local  cause,  it  being  perhaps  primarily  developed 
from  the  less  pigmented  inner  portion  of  the  choroid. 

Sarcoma  is  characterised,  microscopically,  by  the  presence  of  cells 
of  varying  size  and  shape.  They  may  be  stellate,  spindle-shaped,  oval, 
or  round,  having,  perhaps,  well  marked  prolongations.  They  contain 
nuclei  and  nucleoli.  Sometimes  the  cells  are  of  an  extremely  large 
size  (giant  cells  of  Virchow),  and  contain   a  great  number  of  nuclei. 

*  "Krankliaftc  Gresdiwiilste,"  ii,  284;  vide  also  Hulke,  "  R.  L.  O.  IT.  Rep.," 
iii,  283,  and  iv,  85. 


SARCOMA   OF   THE   CHOROID.  447 

Between  the  cells  is  observed  a  variable  quantity  of  scanty,  fibrillated, 
intercellular  tissue.  But  there  is  a  comjjlete  absence  of  an  areolar 
mode  of  arrangement,  and  in  the  pure  form  of  sarcoma  the  cells  are 
not  collected  into  groups  or  nests  within  large  meshes  of  connective 
tissue.  Where  the  latter  arrangement  prevails  in  a  portion  of  the 
tumour,  it  proves  that  it  is  not  a  simple  sarcoma,  but  of  a  mixed  nature, 
viz.,  carcinomatous  sarcoma.  The  cells  often  contain  a  considerable 
amount  of  pigment,  and  the  disease  is  then  termed  melanotic  sarcoma. 
This  is  very  frequently  the  structure  of  intra-ocular  tumours. 

AVith  regard  to  the  pi-oguosis  of  simple  sarcomatous  tumours,  there 
is  no  doubt  that  they  are  decidedly  maHgnant,  and  manifest  a  great  ten- 
dency to  metastasis.  According  to  Vii'chow,  the  degree  of  malignancy 
varies  with  their  structui-e.  Thus  he  states*  that  those  sarcomas  which 
contain  small  cells  (quite  irrespective  of  the  shape  of  the  cell)  are 
far  more  dangerous  than  those  in  which  the  cells  are  large.  On  account 
of  the  small  size  and  vast  quantity  of  the  cells  such  tumoui's  are 
generally  soft,  and  should  be  viewed  with  great  suspicion,  whereas,  the 
giant-cell  (myaloid)  sarcomas  afford  a  relatively  favourable  prognosis. 

There  can  be  no  doubt  of  the  fact,  that  the  intra-ocular  growth  is 
the  primary  affection,  and  that  the  metastatic  tumours  are  secondary. 
They  occui*  chiefly  in  the  liver,  lungs,  brain,  and  kidney.  A  peculiarity 
of  the  sarcomatous  tumours,  which  distinguishes  them  from  the  carcino- 
matous, is,  that  they  show  little  or  no  tendency  to  affect  the  lymphatic 
glands,  and  hence  it  is  more  than  probable  that  the  infection  of  distant 
organs  is  caused  thi-ough  the  blood,  and  not  through  the  lymphatic 
system. 

The  causes  of  intra-ocular  sarcoma  are  yet  uncertain,  but  there  is 
no  doubt  that  it  not  unfrequently  becomes  developed  after  injuries  of 
the  eye.  It  may  also  be  foi'med  in  eyes  which  have  undergone  atrophy 
after  irido-choroiditis,  etc.  Here,  however,  we  must  be  upon  our  guard 
not  to  mistake  cause  and  effect.  But  if  the  eye  has  been  for  many  years 
lost  from  irido-choroiditis,  before  symptoms  of  an  intra-ocular  growth 
reveal  themselves,  it  may,  I  think,  be  fairly  assumed  that  the  latter  is  a 
secondary  afi'ection.  Thus,  Mr.  Bowman  removed  an  eye  affected  with 
melanotic  sarcoma,  which  had  been  lost  from  acute  inflammation  twenty 
years  previously. f 

Sarcoma  of  the  choroid  occurs  most  frequently  after  the  age  of  30, 
being  but  very  rarely  seen  under  the  age  of  15. J  Von  Graefe 
has  never  observed  a  single  instance  in  which  choroidal  sarcoma 
affected  both  eyes,  although  he  has  met  with  cases  in  which  the  second 
eye  became  amaurotic ;  the  ophthalmoscopic  examination  yielding  at 
first  a  perfectly  negative  result,  but  at  a  later  period,  atrophy  of  the 

*  "  Krankhafte  Greschwiilste,"  ii,  269. 
t  "  E.  L.  O.  H.  Rep.,"  iii,  279.  t  "  A.  f.  O.,"  xiv,  2,  106. 


448  DISEASES   OF   THE   CHOROID. 

optic  nerve  set  in.  lu  two  of  these  cases,  melanotic  nodules  were  found 
at  the  base  of  the  brain,  reacting  on  the  chiasma  and  the  optic  nerve 
of  the  other  side. 

Sarcoma  of  the  ciliary  body*  is  also  sometimes  met  with,  and  when 
it  has  acquired  some  size,  it  can  be  distinctly  observed  protruding  into 
the  anterior  chamber.  The  iris  is,  at  this  point,  pushed  aside  from  its 
ciliary  insertion  by  a  dark  brown  tumour,  which  more  or  less  fills  up 
the  anterior  chamber,  its  apex  perhaps  lying  in  contact  with  the  cornea  ; 
the  pupil  is  at  the  same  time  irregularly  distorted.  On  examining 
the  position  of  the  morbid  growth  behind  the  iris,  with  the  oblique 
illumination,  we  may  perhaps  observe  it  encroaching  upon  the  area  of 
the  pupil  and  extending  backwards  into  the  vitreous  humour,  the  lens 
being  generally  displaced  to  a  corresponding  degree  backwards  or 
upwards.  The  surface  presents  a  dark  brown  appearance,  being  either 
quite  smooth  or  somewhat  lobulated. 


(2.)— CARCINOMA  OF  THE  CHOROID. 

We  may  distinguish  two  forms  of  cancer  of  the  choroid,  viz.,  the 
medullary  and  the  melanotic.  I  have,  however,  already  stated  that 
we  cannot  with  any  degree  of  certainty  diagnose  the  true  nature  of 
these  tumours,  except  by  an  examination  of  their  minute  structure. 
We  may,  however,  find  some  assistance  in  framing  our  diagnosis,  by 
remembering  that  cancerous  tumours  show  a  more  rapid  progress  than 
simple  sarcoma,  leading  at  an  earlier  period  to  metastatic  affections,  and 
manifesting  a  great  tendency  to  implicate  the  lymphatic  glands. 

On  a  microscopic  examination  of  medullary  carcinoma,  we  notice 
large  areolar  spaces,  formed  by  fibrillse  of  connective  tissue  ;  and  within 
these  spaces  are  contained  nests  of  variously  shaped  cancer  cells.  The 
latter  may  be  stellate,  fusiform,  ovoid,  or  round,  and  closely  resemble 
epithelial  and  ganglion-cells.  They  contain  a  large  nucleus,  and  within 
this  there  are  numerous  nucleoli. 

The  melanotic  carcdnoTna  is  only  distinguished  from  the  medullaiy, 
by  the  more  or  less  considerable  amount  of  pigment  contained  in  the 
cells  and  the  trabeculsB  forming  the  areolee.  It  may  be  so  great  as  to 
give  a  dark  inky  colour  to  the  tumour.  In  the  melanotic  cancer  there 
are  also  large  areolae  enclosing  nests  of  pigmented  cancer  cells. 

The  melanotic  cancer  is  extremely  dangerous,  and  is  very  prone  to 
recur  at  an  early  date.  Yon  Graefe  states  that  he  does  not  remember 
any  case  in  which   the  apparent  cure  exceeded   four  years.     In  the 

*  Vide  V.  Gracfc's  cases,  "A.  f.  O.,"  xii,  2,  233. 


CARCINOMA   OF   THE   CHOROID.  449 

majority  of  cases  the  disease  recurred  locally  or  in  other  organs  within 
three,  six,  or  twelve  months. 

Sometimes  the  tumour  presents  a  mixed  chai'acter,  being  in  part 
sarcomatous,  in  part  carcinomatous,  and  the  relative  predominance  of 
the  one  over  the  other  may  influence  the  rapidity  of  the  progress  and 
of  the  recurrence.  More  probably,  however,  the  sarcoma  may  have 
existed  for  some  time,  when  the  cancer  elements  become  developed  and 
greatly  hasten  the  growth.  Virchow  does  not  believe  that  the  sar- 
comatous elements  pass  over  into  those  of  cancer,  so  that  the  latter  is 
developed  from  the  sarcoma,  but  that  the  two  conditions  exist  side  by 
side,  arising  out  of  the  same  primary  structui'e,  and  growing  together 
like  two  branches  from  one  stem.* 

The  treatment  to  be  adopted  for  these  tumours  (both  the  sarco- 
matous and  carcinomatous)  is  the  same,  viz.,  the  extirpation  of  the  eye 
as  soon  as  the  diagiiosis  can  be  established  with  anything  like  certainty. 
The  early  removal  of  the  eye  is  indicated,  not  only  because  we  may 
thus  perhaps  be  in  time  to  prevent  the  infection  of  other  organs,  but 
also  to  prevent  the  extension  of  the  disease  to  the  optic  nerve.  In 
removing  the  eyeball,  the  optic  nerve  should  be  cut  veiy  far  back,  so 
that  we  may,  if  possible,  get  beyond  the  seat  of  the  disease. 

If  on  removal  of  the  eye,  the  cut  end  of  the  optic  nerve  looks 
swollen  and  dark,  it  should  be  pulled  out  as  far  as  possible  with  a  pair 
of  forceps,  and  divided  quite  close  to  the  orbit.  This  is  often  very 
difficult  if  we  endeavour  to  look  for  the  nerve,  and  hence  it  is  best, 
as  Mr.  Hutchinsonf  suggests,  to  feel  for  its  trunk  with  our  forefinger, 
and  when  it  is  thus  found  to  seize  its  extremity  with  a  pair  of  strongly 
toothed  forceps,  and  draw  it  forth  and  divide  it. 

Where  the  optic  nerve  is  found  to  be  diseased,  or  the  tumour  has 
extended  into  the  orbit,  the  chloride  of  zinc  paste  should  always  be 
employed  {vide  Tumours  of  Orbit). 


Wecker;|:  describes  a  unique  case  of  myoma  of  the  choroid  which 
occurred  in  his  practice.  The  patient's  left  eye  was  hard,  the  anterior 
ciliary  vessels  dilated  and  tortuous,  and  he  suffered  from  severe 
paroxysms  of  pain.  Nearly  the  whole  of  the  internal  half  of  the  iris 
was  pressed  forward  towards  the  cornea  by  a  reddish  brown  tumour, 
which  also  occupied  the  greater  portion  of  the  pupil.  The  vitreous 
humour  was  clear,  the  optic  disc  somewhat  hyperaemic.  The  eye  was 
enucleated,  and  the  microscopic  examination  of  the  tumour  was  made 
by  Iwanoff,  who  found  that  it  was  a  myo-sarcoma,  there  being  in  it 
distinct  unstriped  muscular  fibres. 

*  "  Krankhafte  Gpschwiilste,"  ii,  182.  f  "  E.  L.  O.  H.  Eep.,"  v,  1,  92. 

%  "  Maladies  des  Yeux  "  (2nd  edition),  1,  545. 

2   G 


450  DISEASES   OF   THE   CHOROID. 

Leber*  again,  describes  a  very  interesting  and  peculiar  case  in 
which  the  sarcoma  of  the  choroid  assumed  a  distinctly  cavernous 
character. 

8.— FORMATION  OF  BONE  IN  THE  CHOROID. 

A  formation  of  true  bone  is  not  unfrequently  met  withf  on  the 
inner  surface  of  the  choroid,  in  eyes  which  have  undergone  atrophy 
and  become  shrunken.  These  osseous  deposits  may  appear  in  the  form 
of  small  circumscribed  spots  or  plates,  or  they  may  be  so  extensive  as 
to  form  a  complete  hollow  cup,  reaching  from  the  ciliary  processes  to 
the  optic  nerve,  and  being  perforated  by  the  latter.  In  close  apposition 
to  this  formation  of  bone  may  often  be  noticed  cartiiaginous  tissue. 

The  shrunken  eyeball  in  which  a  deposit  of  bone  has  taken  place,  is 
not  unfrequently  very  painful,  both  to  the  touch  and  spontaneously, 
and  may  give  rise  to  sympathetic  inflammation. 

9.— COLOBOMA  OF  THE  CHOROID. 

The  ophthalmoscopic  symptoms  presented  by  this  condition  are  very 
striking  and  characteristic,  and  show  a  remarkable  similarity  in  all 
cases,  although,  of  course,  the  extent  of  the  coloboma  and  of  the  bulging 
backwards  of  the  sclerotic  greatly  influence  these  appearances.  Liebreich 
gives  an  admirable  illustration  of  this  condition  in  his  Atlas.  J 

With  the  ophthalmoscope,  there  is  observed  a  most  peculiar,  large, 
white  figure  at  the  lower  part  of  the  fundus,  extending  perhaps  nearly 
up  to  the  disc,  or  even  ejnbracing  this  in  its  expanse.  Anteriorly  it  may 
reach  more  or  less  closely  up  to  the  ciliary  processes,  or  even  quite  up 
to  the  corresponding  coloboma  of  the  iris.  Together  with  this  colo- 
boma of  the  choroid,  there  always  exists  a  staphylomatous  bulging 
backwards  of  the  sclerotic.  This  may  be  nearly  of  the  same  depth 
throughout,  or  suddenly  and  abruptly  increase  in  depth,  Avhich  can  be 
distinctly  observed  with  the  ophthalmoscope,  as  it  produces  a  peculiar 
appearance  in  the  course  of  the  retinal  vessels,  which  will  be  seen 
suddenly  to  dip  round  this  edge  and  be  slightly  interrupted  in  their 
course,  thus  giving  rise  to  a  marked  parallax.  These  appearances 
can  be  well  studied  in  Liebreich's  illustration. 

On  the  white  expanse  are  noticed  the  retinal  vessels,  which  do  not, 
however,  pursue  their  regular  course,  but  undergo  peculiar  windings, 
some  twisting  and  curling  round  over  the  edge  of  the  coloboma.     The 

*  "  A.  f.  O.,"  xiv,  2,  221. 

t  Vide  Wcdl's  Atlas  dcr  ratliologiscbcn  Histologic  dcs  Augcs. 

X  riuic  XII,  fig.  5. 


RUPTURE  OF  THE  CHOROID.  451 

presence  of  the  retina,  or  at  least  of  some  attenuated,  vicarious  membrane 
is  proved  by  the  appearance  of  the  retinal  vessels  on  the  surface  of  the 
coloboma.  The  retina  may  either  lie  in  apposition  with  the  sclerotic, 
or  be  stretched  across  the  bulge  in  the  latter,  and  in  this  case  it  is  often 
slightly  folded,  so  that  branches  of  its  vessels  may  appear  to  sprinf)" 
directly  from  the  sclerotic,  on  account  of  their  continuity  with  the  other 
retinal  vessels  being  hidden  by  the  folds.  Traces  of  choroidal  vessels 
may  also  be  noticed  upon  the  white  figure.  The  margin  of  the  latter  is 
very  sharply  defined,  of  a  dark  reddish-brown  or  coffee- coloured  tint, 
and  strongly  pigmented.  If  the  cleft  stops  short  of  the  disc,  it  will  be 
divided  from  the  latter  by  a  sharp  line  of  demarcation,  and  a  more  or 
less  normal  portion  of  fundus ;  whereas  if  the  disc  is  included  in  the 
coloboma,  its  appearance  is  remarkably  changed,  for  it  can  hardly  be 
distinguished  from  the  rest  of  the  white  figure  except  by  a  more 
rosy-gi'ey  tint ;  its  form  being  elliptic,  with  its  long  diameter  placed 
liorizon  tally. 

If  the  anterior  extremity  of  the  coloboma  does  not  reach  up  to  the 
cleft  in  the  iris,  there  are  noticed  small  rudimentary  ciliary  pro- 
cesses, and  it  is  divided  from  the  coloboma  of  the  iris  by  a  more  or  less 
extensive  portion  of  perhaps  darkly  pigmented  fundus,  traversed  by  a 
kind  of  raphe,  or  white  stripe*  (sometimes  there  are  two  or  three). 
Where  the  coloboma  of  the  choroid  touches  that  of  the  iris,  the  ciliary 
processes  may  be  completely  wanting.  Samischf  narrates  a  very 
interesting  case  of  coloboma  of  the  iris  and  choroid,  in  which  the  former 
was  divided  from  the  pupil  by  a  narrow  band,  which  was  probably  a 
remnant  of  the  pupillaiy  membrane.  Baumler  J  has  also  noticed  such 
little  bands  traversing  the  area  of  the  pupil  in  cases  of  coloboma. 

If  the  region  of  the  yellow  spot  is  not  involved,  the  sight  may  be 
tolerably  good,  but  there  is  always  an  inteiTuption  in  the  field  of  vision 
(scotoma),  corresponding  in  size  and  situation  to  the  coloboma  of  the 
choroid. 

Liebreich  has  also  observed  and  figured  (Atlas,  PI.  xii,  fig.  4)  the 
vex'y  rare  and  curious  condition  of  a  coloboma  of  the  sheath  of  the 
optic  ucr^■e. 

10.— RUPTURE  OF  THE  CHOROID. 

Severe  blows  upon,  or  contusions  of  the  eye  by  the  fist  or  some  blunt 
body,  as,  for  instance,  a  piece  of  wood,  may  produce  rupture  of  the 
choroid  by  simple  concussion  of  the  eye,  without  any  injiuy  or  i-upture 

*  Vide  Arlt,  "  Krantheiten  cles  Axiges,"  ii,  128  ;  also  Samisch,  "  Kl.  Monatsbl.," 
1867,  p.  87. 

t  L.  c,  p.  87. 

j  "  W'urzbiirger  Med.  Zeitsclirilt,"  iii,  84. 


452  DISEASES   OF   THE   CHOROID. 

of  tlie  sclerotic  or  retina.  The  accident  is  generally  followed  by  exten- 
sive liEemorrhage  from  the  choroid,  and  more  or  less  severe  inflammatory 
symptoms.  The  vitreous  humour  often  becomes  difiusely  clouded  and 
traversed  by  membranous  opacities,  which  may  be  due  to  inflammatory 
exudations  or  haemorrhagic  efi"usions.  If  the  vitreous  humour  is  sufii- 
ciently  clear  to  permit  of  an  examination  of  the  fundus,  we  notice  the 
presence  of  one  or  more  pale  linear  stripes  in  the  region  of  the  yellow 
spot.  This  appearance  is  produced  by  the  rupture  of  the  choroid,  which 
is  generally  somewhat  irregular  in  outline,  and  divided,  perhaps,  into 
one  or  more  ofi'shoots.  Its  edges  are  smooth,  or  shghtly  notched  and 
irregular,  and  fringed  or  studded  with  deposits  of  pigment,  or  little 
h^emorrhagic  effusions.  As  the  blood  becomes  absorbed,  the  eSusions 
may  either  entirely  disappear  or  leave  behind  small  pale  patches  in  the 
choroid,  and  the  linear  rupture  assumes  a  bright,  ghstening,  tendinous 
appearance,  which  is  due  to  the  sclerotic  being  quite  exposed  on  account 
of  the  absorption  of  the  blood.  Within  the  expanse  of  the  white  figui'e 
a  choroidal  vessel  may,  perhaps,  be  observed.  The  fundus  around  the 
rupture  (except  perhaps  in  its  immediate  vicinity)  is  generally  quite 
normal.  The  retina  is  also  frequently  uninjured  and  free  from  any 
rupture,  for  its  vessels  either  pass  quite  unaltered  over  the  scar  in 
the  choroid,  or  present  only  a  very  faint  interruption.  Ruptures  in  the 
choroid  generally  occur  in  the  region  of  the  yellow  spot,  and  run  in  a 
vertical  direction ;  they  are  sometimes  straight,  in  other  cases  arched  or 
crescentic,  the  concavity  of  the  arch  being*  turned  towards  the  disc.  In 
some  cases  there  is  only  one  rupture,  in  others  two  or  three,  of  nearly 
equal  or  varying  size,  and  the  one  end  of  the  rent  may  split  up  and  be 
divided  into  two  or  three  little  branchlets.* 

The  sight  is  at  first  often  greatly  impaired,  on  account  of  the  hsemorr- 
hagic  efiusions  into  the  choroid  and  vitreous  humour,  or  the  iaflamma- 
tory  complications.  As  the  former  become  absorbed  and  the  vitreous 
humour  regains  its  transparency,  the  sight  may  become  greatly  improved, 
and  even  quite  restored ;  but  this  is  exceptional,  for  mostly  it  remains 
more  or  less  considerably  impaired.  The  field  of  vision  is  sometimes 
contracted  at  the  periphery,  and  there  may  also  be  interruptions 
(^scotomata)  in  it,  corresponding  in  situation  to  the  rupture  in  the 
choroid. 

Although  in  favourable  cases,  the  cicatrization  of  the  rupture  in  the 
choroid  is  not  followed  by  any  subsequent  afiection  of  the  retina 
or   optic  nerve,   yet  the   former   may  afterwards   become   detached.f 

*  Amongst  other  interesting  cases  of  rupture  of  tl\e  choroid,  I  would  especially 
call  the  reader's  attention  to  the  following,  described  by  Von  Gracfe,  "  A.  f.  O.,"  i,  1, 
402  ;  Von  Animon,  ibid.,  i,  2,  124 ;  Frank,  "  R.  L.  O.  H.  Rep.,"  iii,  84 ;  Siimisch, 
"Kl.  Monatsbl.,"  1866,  HI  and  1867,  32;  Haasc,  "  Kl.  Monatsbl.,"  1866,  257. 

t  "  Kl.  Monatsbl.,"  186G,  p.  111. 


HEMORRHAGE   FROM   THE   CHOROID.  453 

Dr.  Frank*  also  narrates  a  case  in  which  rupture  of  the  clioroid  was 
followed  by  atrophy  of  the  optic  nerve. 

The  treatment  must  principally  consist  in  hastening  the  absorption 
of  the  hajmorrhagic  effusions  into  the  choroid  and  vitreous  humour, 
and  for  this  purpose  the  compress  bandage  and  the  repeated  applica- 
tion of  the  artiticial  leech  will  be  found  most  serviceable. 

Lidded  ivounds  of  the  sclerotic  and  choroid  are  not  generally  accom- 
panied by  a  protrusion  (hernia)  of  the  choroid  but  the  edge  of  the 
wounded  choroid  may  be  forced  out  between  the  lips  of  the  sclerotic 
incision  by  the  exuding  vitreous  humour.  In  wounds  of  the  choroid, 
there  is  often  a  considerable  effusion  of  blood  into  the  choroid  and 
vitreous  humour. 

11.— HEMORRHAGE  FROM  THE  CHOROID. 

Extravasations  of  blood  fi-om  the  choroid  may  be  produced  by  an 
accident,  such  as  a  blow  upon  the  eye,  or  a  wound  impHcating  the 
sclei'otic  and  choroid.  But  it  also  occurs  in  diseases  of  the  eye  which 
influence  the  intra-ocular  circulation — as  for  instance  glaucoma,  sclero- 
tico- choroiditis  posterior,  etc.,  and  produce  a  congestion  of  the  cho- 
roidal vessels,  more  especially  if  the  latter  should  be  diseased.  In 
such  cases,  any  sudden  strain,  such  as  violent  vomiting  or  retching,  or 
the  sudden  relief  of  the  intra-ocular  tension  by  paracentesis  or  iridec- 
tomy, may  cause  a  rupture  of  some  of  the  smaller  choroidal  vessels,  and 
perhaps  considerable  haemorrhage.  It  may  also  occur  spontaneously, 
or  after  severe  and  protracted  exertion  of  the  eye,  as  in  engraving, 
sewing,  microscopizing,  etc. 

The  blood  may  be  effused  between  the  choroid  and  sclerotic,  into 
the  tissue  of  the  choroid,  or  between  the  latter  and  the  retina.  If  the 
haemorrhage  is  but  slight,  it  will  simply  produce  small  circumscribed 
ecchymoses  in  the  choroid,  but  if  it  is  considerable  in  quantity,  it  may 
cause  detachment  of  the  retina,  or  perforate  the  latter,  and  escape  into 
the  vitreous  humour.  This,  as  has  been  already  stated  in  the  article  upon 
haemorrhage  into  the  vitreous  humour,  p.  316,  will  chiefly  depend  upon 
the  situation  of  the  haemorrhage,  for  if  the  latter  takes  place  near  the  ora 
serrata,  it  is  more  likely  to  perforate  the  retina  (on  account  of  the  thin- 
ness of  the  latter  at  this  point),  and  to  escape  into  the  vitreous  humour. 
Whereas,  if  the  extra v'asation  occurs  near  the  posterior  pole  of  the  eye,  it 
is  more  apt  to  produce  detachment  of  the  retina.  Esmarchf  has  narrated 
a  very  interesting  case  of  extravasation  of  blood  from  the  choroid,  with 
perforation  of  the  retina  in  the  region  of  the  yellow  spot  and  escape  of 
the  blood  into  the  vitreous  humour,  where  it  gradually  underwent 
absorption,  until  nothing  remained  but  a  small  dark  speck  about  the 

*  "  R.  L.  O.  H.  Reports,"  iii,  84.  +  "  A.  f.  O.,"  iv,  1,  350. 


454  DISEASES  OF   THE   CHOROID. 

size  of  a  pin's  head,  tlie  perforation  in  the  retina  having  healed  without 
leaving  any  trace  behind  it.  Sometimes,  however,  the  position  of  the 
little  cicatrix  may  remain  recognisable  as  a  small  black  pigment  spot. 
Effusion  of  blood  between  the  sclerotic  and  choroid  may  produce 
detachment  of  the  latter. 

With  the  ophthalmoscope,  effusions  of  blood  into  the  choroid  may 
be  recognised  by  their  presenting  the  appearance  of  uniform,  dark, 
cherry-coloured  patches,  of  varying  size  and  shape,  being  irregular, 
circular,  ovoid,  etc.  Their  edges  may  be  sharply  defined,  or  some- 
what indistinct  and  irregular.  The  colour  of  the  apoplexy  is  uniformly 
red,  and  not  striated,  nor  are  its  edges  serrated  or  "feathery,"  as  is 
the  case  when  blood  is  effused  into  the  inner  layers  of  the  retina,  and 
follows  the  course  of  the  optic  nerve  fibres.  Again,  the  retinal  vessels 
can  be  distinctly  seen  to  pass  straight  over  the  efi'usion,  without  being- 
interrupted  or  hidden  by  it.  If  no  retinal  vessel  should  be  situated 
over,  or  in  very  close  proximity  to,  the  heemorrhage,  the  situation  of 
the  latter,  upon  a  plane  deeper  than  that  of  the  retina,  is  best  recog- 
nised by  the  aid  of  the  binocular  ophthalmoscope.  If  the  disease  has 
lasted  some  little  time,  some  of  the  neighbouring  extravasations  have 
probably  undergone  partial  absorption,  and  given  rise  to  peculiar 
appearances  in  the  choroid,  which  will  aid  us  in  our  diagnosis  of  the 
exact  situation  of  any  special  ecchymoses.  Dui'ing  the  process  of 
absorption,  the  effusion  gradually  assumes  a  paler  and  more  yellowish 
white  tint,  and  becomes  fringed  by  a  circlet  of  pigment.  The  smaller 
ecchymoses  may  leave  no  trace  behind  them,  or  only  a  small  pigment 
spot. 

If  the  hiBmorrhage  is  but  slight,  and  is  situated  at  the  periphery 
of  the  fundus,  it  may  produce  no  impairment  of  vision,  or  only  a  small 
scotoma ;  but  it  is  very  different  when  it  is  situated  at  or  near  the 
yellow  spot,  for  then  it  may  very  greatly  affect  the  sight,  and  render 
the  patient  unable  to  read  even  large  type ;  a  more  or  less  dense  cloud 
or  spot  covering  the  letters  and  rendering  them  indistinct. 

The  treatment  must  be  the  same  as  that  which  is  adopted  for 
hypersemia  of  the  choroid  and  retina,  and  htemorrhagic  effusions  into 
the  latter. 

12.— DETACHMENT  OF  THE  CHOROID  FROM  THE 
SCLEROTIC. 

A  few  cases  of  this  very  rare  affection  have  been  described,  more 
especially  by  Von  Graefe  and  Liebreich,*  and  a  very  beautiful  illustra- 
tion of  this   condition  will  be  found  in   the  latter'.s  Atlas. f     Iwanoff}: 

*  "  A.  f.  O.,"  iv,  2,  22G ;  Licbrcieh,  ibid.,  v,  2,  259. 
t  PI.  vii,  fig.  4.  X  "  A.  f.  O.,"  xi,  1,  191. 


DETACHMENT   OF   THE   CHOROH)   FROM   THE   SCLEROTIC.       455 

has  also  given  a  very  careful  desci-iption  of  the  dissection  of  an  eye 
atlected  with  detachment  of  the  choroid. 

The  ophthalmoscopic  symptoms  of  this  disease  are  very  marked  and 
characteristic.  A  more  or  less  considerable,  globular  protrusion 
is  observed  in  the  vitreous  humour.  Its  outline  is  sharply  defined, 
its  surface  tense  and  smooth  and  devoid  of  all  wrinkles  or  foldings, 
and  upon  it,  the  retinal  vessels  can  be  distinctly  traced  as  they 
pass  over  it  from  the  normal  fundus.  But  the  most  characteristic 
symptom  of  all,  is  the  appearance  of  the  choroidal  vessels  and  intra- 
vascular spaces  lying  close  beneath  the  retina.  At  the  angle  where  the 
protrusion  springs  from  the  normal  fundus,  the  retina  is  not  unfre- 
quently  somewhat  detached,  becoming  still  more  so  at  a  later  date. 
The  colour  of  the  protrusion  varies  from  a  pale  yellowish-grey  tint  to 
a  darker  red,  according  as  the  fluid  causing  the  detachment  is  of  a  serous 
or  hasmorrhagic  natui'e.  Its  surface  is  not  unfreqnently  studded  with 
small  ecchymoses.  On  account  of  the  protrusion  being  situated  so  far  in 
front  of  the  focal  length  of  the  eye,  it  can  be  distinctly  seen  in  the  erect 
image  at  some  distance  from  the  eye,  afibrding  a  faint  yellow  reflex  in 
place  of  the  bright  red  glow  of  the  normal  fundus.  The  retinal  vessels 
can  also  be  dLstinctly  seen  to  traverse  its  surface.  It  may  be  especially 
distinguished  from  simple  detachment  of  the  retina,  by  the  fact  that  it 
does  not  oscillate,  tremble,  or  fall  into  small  wavy  folds  when  the  eye 
is  moved  in  diflerent  directions,  but  retains  its  tense,  smooth,  bladder- 
like appearance. 

It  may  be  very  difficult,  or  indeed  quite  impossible,  to  determine 
whether  the  detachment  of  the  choroid  is  due  to  a  sei'ous  or  hsemorr- 
hagic  efiusion,  or  to  some  morbid  growth  pressing  it  forward.  And 
only  as  the  disease  progresses  shall  we  able  to  decide  this  question  with 
certainty,  for  simple  detachment  of  the  choroid  by  fliiid  always  ends  in 
irido-choroiditis,  and  softening  and  atrophy  of  the  eyeball.  Whereas,  in 
intra-ocnlar  tumours,  symptoms  of  increased  tension  and  glaucomatous 
inflammation  generally  supervene  as  the  disease  progresses. 


? 


Chapter  XII. 
GLAUCOMA. 


We  have  now  to  turn  our  attention  to  one  of  the  most  important  and 
dangerous  diseases  of  the  eye,  viz.,  glaucoma;  a  disease  whose  timely- 
treatment  by  iridectomy  will  yield  the  most  favourable  results,  but 
which,  if  allowed  to  run  its  course  unchecked,  except  perhaps  by  in- 
efficient remedies,  sooner  or  later  dooms  the  eye  to  irremediable  blind- 
ness. It  is,  therefore,  of  the  utmost  consequence  that  all  surgeons 
should  be  thoroughly  conversant  with  the  different  symptoms  which  it 
may  present  in  its  various  forms,  so  that  they  may  be  able  at  once  to 
recognise  this  dangerous  and  insidious  affection,  and  to  combat  and 
subdue  it  before  it  is  too  late. 

The  term  glaucoma  was  applied  by  Hippocrates  to  all  opacities 
situated  behind  the  pupil.  After  a  time,  it  was  confined  to  those  which 
presented  a  g-reen  appearance,  the  nature  of  which  was  not,  however, 
understood,  although  the  fact  was  recognised  that  such  gi-een  opacities 
were  not  curable  by  operation.*  By  some,  the  seat  of  the  affection 
was  supposed  to  be  in  the  vitreous  humour,  by  others,  in  the  retina  and 
optic  nerve.  At  a  later  period,  it  was  thought  that  glaucoma  was  due 
to  a  peculiar  inflammation  of  the  choroid,  which  occui^red  most  fre- 
quently in  gouty  persons,  hence  it  was  termed  arthritic  ophthalmia,  a 
name  still  retained  by  some  writers.  Lawrence  considered  that  the 
symptoms  of  glaucoma  were  caused  by  an  affection  of  the  retina  and 
choroid.  Weller  gave  a  most  excellent  and  graphic  description  of  the 
symptoms  of  glaucoma,  including  in  it  many  of  the  principal  and  most 
important  points,  e.g.,  the  intermitting  course  of  the  disease,  the 
sluggishness  and  dilatation  of  the  pupil,  the  circumorbital  pain,  the 
rainbows  round  a  candle,  &c.  He  also  made  mention  of  the  tenseness 
of  the  eyeball,  but  Mackenzie  first  pointed  out  (in  1830)  the  importance 
of  the  latter  symptom. 

In    1851,   Helmholtz  discovered   the    ophthalmoscope,   which    has 


*  For  an  interesting  historical  resume  of  glaucoma,  I  would  refer  the  reader  to 
Dr.  Hoifmann's  excellent  paper  on  Glaucoma,  "  A.  f.  O.,"  viii,  2.  With  regard  to 
the  literature  of  this  subject,  I  would  direct  his  attention  especially  to  Von  Graefe's 
Papers,  "  A.  f.  O.,"  iii,  2  ;  iv,  2  ;  viii,  2. 


fiLAUCOMA.  457 

proved  of  such  incalculable  value  in  diseases  of  the  eye,  and  has  so 
completely  revolutionized  ophthalmic  sui-gery.  The  first  results  of  the 
ophthalmoscopic  examination  of  cases  of  glaucoma  were  negative  ;  soon, 
however,  it  was  ascertained  thab  there  always  existed  a  peculiar  altera- 
tion in  the  optic  disc  in  all  cases  of  well-marked  glaucoma.  In  1854, 
Edward  Jiiger  gave  an  excellent  illustration  of  the  ophthalmoscopic 
appearances  of  the  optic  nerve  entrance  in  a  case  of  glaucoma,  showing 
the  peculiar  displacement  of  the  vessels  at  the  edge  of  the  disc,  the 
sHght  rim  surrounding  the  latter,  &c.  It  was,  however,  reserved  for 
the  great  genius  of  von  Graefe  to  unite  these  various  and  disjointed 
links  of  the  chain  of  symptoms  presented  by  glaucoma,  and,  welding 
them  into  one  connected  whole,  not  only  to  found  the  modern  doctrine 
of  glaucoma,  but,  at  the  same  time,  to  bless  humanity  with  a  cui'e  for 
this  hitherto  irremediable  disease.  Soon  after  Jager's  dehneation  of 
the  ophthalmoscopic  appearances  of  the  optic  disc,  von  Graefe  described 
these  peculiar  appearances  still  more  accurately,  and  at  the  same  time 
pointed  out  a  most  important  fact,  viz.,  that  an  arterial  pulsation  exists 
in  the  optic  nerve  in  glaucoma,  being  either  spontaneous,  or  producible 
by  a  very  slight  pressure  upon  the  eyeball,  a  pressure  far  less  than  is 
necessary  for  its  production  in  the  normal  eye.  Within  a  short  time 
afterwards,  he  also  discovered  that  the  pecuHar  appearance  of  the  optic 
disc,  which  had  been  supposed  by  him  and  other  observers  to  be  caused 
by  an  arching  forward  of  the  optic  nerve  entrance,  was  in  reality  due  to 
its  being  excavated  or  cupped.  He  at  once  recognised  the  connection 
of  these  two  symptoms  (the  excavation  and  the  spontaneous,  or  easily 
producible  arterial  pulsation)  with  the  increased  hardness  of  the  globe, 
and  his  clinical  observations  soon  showed  him  that  all  the  other 
symptoms  were  also  closely  connected  with  this  augmented  tension. 
The  next  problem  was,  to  solve  how  this  tension  might  be  permanently 
diminished.  All  the  usual  remedies,  such  as  mercurials,  antiphlogistics, 
diuretics,  diaphoretics,  had  proved  as  insufficient  in  his  hands,  as  in 
those  of  other  practitioners.  Mydriatics,  which  had  been  found  to 
diminish  intra-ocular  pressure,  were  next  had  recourse  to,  but  they 
also  proved  of  no  avad.  He  then  tried  tapping  the  anterior  chamber, 
but  tliis  was  only  followed  by  a  temporary  benefit,  wliich  soon  passed 
away  again.  The  disease  gradually  progressed,  nor  could  the  relapses 
be  stayed  by  a  methodical  repetition  of  the  paracentesis,  for  he  found 
that  its  therapeutical  effect  became  each  time  less,  and  finally  null,  as 
far  as  the  sight  was  concerned.  In  only  two  cases,  out  of  a  great 
number  thus  treated,  did  it  prove  of  lasting  benefit. 

Paracentesis  having  been  of  no  avail  in  permanently  reducing  the 
intra-ocular  tension,  he  next  had  recourse  to  iridectomy,  having  found 
that  it  proved  of  great  benefit  in  ulcerations  and  infiltrations  of  the 
cornea,  by  diminishing  the  tension ;  and  that  in  cases  of  partial  staphy- 


458  GLAUCOMA. 

loma  of  the  cornea,  and  in  staphyloma  of  the  sclerotic,  the  protruding 
part  often  receded  completely  after  this  operation. 

He  first  tried  iridectomy  in  glaucoma  in  1856,  and  soon  found  that 
it  not  only  permanently  diminished  the  intra-ocular  tension,  but  that 
it  might  indeed  be  regarded  as  a  true  curative  treatment  of  the  glauco- 
matous process,  having,  however,  like  every  other  therapeutic  agent,  its 
natural  limits.  Since  that  time,  iridectomy  has  been  recognised  by 
most  of  the  eminent  oculists  in  Europe  as  the  only  cure  known,  at 
present,  for  glaucoma;  but  although  it  has  achieved  most  brilliant 
results  in  the  hands  of  many  of  our  most  distinguished  English  oph- 
thalmic surgeons — amongst  whom  I  would  more  particularly  instance, 
Messrs.  Bowman  and  Critchett,  who  have  from  the  commencement  been 
its  stanch  and  warm  supporters — there  are  yet  some  English  oculists 
of  repute  who  either  condemn  the  operation  completely,  or  uphold  it  in 
so  luke-warm  a  manner  as  in  reality  to  "  damn  it  with  faint  praise." 

My  own  wide  experience  of  the  beneficial  effects  of  iridectomy  in 
glaucoma  enables  me,  not  only  to  recommend  the  operation  most 
strongly,  but  even  to  urge  upon  the  profession  to  trust  to  no  other 
remedies,  as  they  have  all  proved  insufficient,  and  as  we  should  thus 
permit  the  most  valuable  time,  when  an  iridectomy  might  still  save 
the  eye,  to  pass  irrevocably  away.  We  shall  see,  hereafter,  that  an 
accurate  prognosis  of  the  benefits  to  be  expected  from  iridectomy  may 
be  made  in  the  majoi'ity  of  cases,  and  it  will  be  shown  why  the  opera- 
tion may  have  proved  unsuccessful  in  the  hands  of  some  practitioners. 
But  too  frequently  impossibihties  were  expected  of  it ;  it  was  tried,  for 
the  first  and  only  time  perhaps,  in  chronic  cases  of  glaucoma,  which 
were  beyond  all  help ;  it  proved,  as  might  have  been  foretold,  unsuc- 
cessful, and  was  then  at  once  discarded  as  useless. 

The  commencement  of  the  disease,  the  development  of  the  dif- 
ferent symptoms,  and  the  course  which  glaucoma  may  run,  present 
numerous  variations,  and  for  this  reason  a  precise  classification  is 
somewhat  difficult.  But  on  closer  observation,  it  will  be  found  that  the 
several  varieties  also  show  a  great  tendency  to  pass  over  into  each 
other.  The  family  resemblance  of  these  different  forms  is  very  marked, 
for  they  are  distinguished  from  the  commencement  by  certain  charac- 
teristic symptoms,  and  although  they  will  vary  somewhat  in  their 
course,  they  all,  but  too  surely,  lead,  sooner  or  later,  to  that  last  hope- 
less condition  in  which  the  eyeball  is  stony  hard,  the  pupil  widely 
dilated  and  fixed,  the  refractive  media  cloxided,  the  optic  disc  cupped, 
and  the  sight  either  entirely  or  nearly  entirely,  lost ;  that  condition,  in 
short,  to  which  our  forefathers  confined  the  term  glaucoma.  The 
modern  school  of  ophthalmology,  however,  no  longer  limits  the  name 
glaucoma  to  this  last  hopeless  condition,  but  embraces  in  it  all  the 
varieties   of  the  disease  from  their  commencement,  which  lead  to  this 


ACUTE  INFLAMMATORY  GLAUCOMA.  459 

last  stage.  In  regarding  the  difterent  varieties  of  glaucoma  from  a 
clinical  point  of  view,  we  are  particularly  struck  by  the  fact,  that  one 
class  of  cases  is  distinguished  from  the  commencement  by  more  or  less 
marked  inflammatory  symptoms ;  whilst  another  appears  to  be  free 
from  inflammation,  although  in  its  course  inflammatory  symptoms, 
even  of  an  acute  kind,  often  make  their  appearance.  We  may,  there- 
fore, divide  cases  of  glaucoma  into  two  principal  classes  : — 

I.  Cases  attended  with  inflammatory  symptoms. 

II.  Cases  in  which  there  are  ai^parenthj  no  inflammatory  symptoms 
present. 

Glaucoma  may  exist  as  a  primary  disease,  or  may  complicate  a  pre- 
viously existing  affection. 

We  find  that  the  different  varieties  of  glaucoma  show  certain 
common  characteristics,  and  we  may  generally  recognise  the  four  follow- 
ing stages : — 

1.  A  premonitory  stage  (glaucoma  imminens,  incipiens,  of  Von 
Graefe). 

2.  A  stage  in  which  the  glaucoma  is  fully  developed  (glaucoma 
evolutum,  confirmatum.  Von  Graefe). 

3.  A  stage  in  which  quantitative  perception  of  light  has  been  com- 
pletely lost  for  some  time  (glaucoma  absolutum,  consummatum,  Von 
Graefe). 

4.  A  stage  in  which  the  eye  undergoes  glaucomatoiTS  degeneration 
(Von  Graefe). 

We  distinguish  two  principal  forms  of  inflammatory  glaucoma,  the 
acute  and  the  chronic. 


1.— ACUTE   INFLAMMATORY    GLAUCOMA    (SYNOM. 
ARTHRITIC  OPHTHALMIA). 

Premonitory  Stage. — In  the  gi'eat  majority  of  cases  (75  p.  c.) 
there  is  a  premonitory  stage,  which  is  characterised  by  the  pre- 
sence of  several  or  all  the  following  symptoms,  which  are,  however,  of 
periodic  occurrence,  there  being  in  the  interval  a  perfect  intermission. 
When  this  ceases  to  be  the  case,  when  there  are  no  longer  perfect 
intermissions,  but  only  remissions  of  the  symptoms,  we  can  no  longer 
designate  it  the  premonitory  stage,  but  must  regard  it  as  confirmed 
glaucoma. 

I.  Increased  Tension   of  the  EijehalJ* — This  is  generally  not  very 

*  Tlie  method  of  ascertaining  and  noting  tlie  degree  of  intra-oeular  tension  is 
fully  explained  in  tlie  Introduction,  p.  2. 


460  GLAUCOMA. 

considerable,  and  never  reaches  the  liighest  degree.    In  families  in  which 
glaucoma  is  hereditary,  a  marked  increase  of  tension  is  often  met  with, 
even  in  early  life,  although  the  disease  may  not  break  out  till  a  much 
later  period,  or  even  not  at  all.    In  such  cases  there  can  be  no  objection 
to  look  upon  this  abnormal  tension  as  a  predisposing  element  of  glau- 
coma, more  particularly  if  it  be  accompanied  by  hypermetropia,  and  a 
disproportional  diminution  of  the  range  of  accommodation.      It  has 
been  supposed  by  some,  that  the  increased  degree  of  tension  always 
precedes,  for  a  longer  or  shorter  period,  the  other  symptoms  of  glau- 
coma ;  von  Graefe  has,  however,  met  with  several  marked  exceptions  to 
this  rule.     In  some  cases  in  which  he  operated  for  glaucoma  in  the  one 
eye,  the  other  was  found  to  be  of  a  perfectly  normal  tension  at  the  time 
of  operation,  but  was   soon  after  attacked  by  glaucoma,  in  one  case 
even  by  glaucoma  fulminans.     But  an  increase  in  the  tension  of  the 
eyeball  should  always  excite  our  suspicion,  and  should  at  once  lead  us 
to  examine  as  to  the  presence  of  other  symptoms  of  glaucoma ;   if  we 
find  none,  we  should  still  watch  the  eye  with  care,  and  warn  the  patient 
carefully  to  observe  whether  any  other  symptoms  begin  to  show  them- 
selves,  e.g.,   rainbows  round  a  candle,  rapidly  increasing  presbyopia, 
periodic  dimness  of  vision,   &c.     We  must  be  upon  our  guard  against 
the  but  too  frequent  error,  that  a  sense  of  fulness  or  tension  within  the 
eye  experienced  by  the  patient,  is  any  proof  of  the  increased  hardness 
of  the  eyeball.     For   this  feeling  of   fulness   may  exist  without   the 
slightest  increase  of  tension.     Another  frequent  error  is,  to   suppose 
that  all  acute  inflammations  of  the  eye  are  accompanied  by  an  increase 
in  the  intra-ocular  pressure.     A  careful  examination  of  ordinary  cases 
of  acute  inflammation  of  the  conjunctiva,  cornea,  iris,  &c.,  will  at  once 
prove  the  fallacy  of  this  opinion,  for  the  tension  will  be  found  normal. 
If  the  degree  of  tension  is  increased,  we  must  regard  it  as  a  dangerous 
complication,  which  is  to  be  carefully  watched,  lest  it  be  the  precursor 
of  other  glaucomatous  symptoms. 

2.  Bcupid  Increase  of  any  pre-existing  Presbyopia. — As  the  persons 
attacked  by  glaucoma  are  mostly  beyond  45  or  50  years  of  age,  some 
degree  of  presbyopia  is  generally  already  present,  but  it  is  found  that 
this  often  increases  in  a  very  rapid  and  marked  manner  during  the  pre- 
monitory stage  of  glaucoma ;  so  that  the  patient  may  be  obliged,  in  the 
course  of  a  few  months,  frequently  to  change  his  reading-glasses  for 
stronger  and  stronger  ones.  This  rapid  increase  in  the  presbyopia 
appears  to  be  not  so  much  due  to  a  flattening  of  the  cornea  through  an 
increase  in  the  intra-ocular  pressure,  as  to  the  action  of  this  pressure 
upon  the  nerves  supplying  the  ciliary  muscle,  thus  causing  paralysis  of 
the  latter.  Haffmann  has  called  particular  attention  to  the  fact  that 
hypermetropia  very  frequently  occurs  together  with  glaucoma.  It 
appears  probable  that  hypermetropic  eyes  are  more  prone  to  glaucoma 


ACUTE  INFLAMMATORY  GLAUCOMA.  461 

than  others  ;  but  hypermetropia  may  also  be  developed  in  the  course 
of  the  disease.  The  cause  of  this  is,  however,  still  quite  iincertain,  it 
is  probably  to  be  sought  for  in  some  changes  in  the  crystalline  lens 
(rapidly  progressive  senile  involution),  by  which  the  refractive  power 
of  the  latter  is  considerably  diminished. 

o.  Venous  Hyperce-mia. — The  congestion  of  the  ciliary  veins  is 
generally  slight  during  the  premonitory  stage,  and  they  never  present 
that  peculiar  tortuous,  dilated  appearance,  so  characteristic  of  chronic 
glaucoma.  Generally,  only  a  few  scattered,  dilated  veins  are  seen 
running  over  the  sclerotic.  On  examination  with  the  ophthalmoscope, 
the  retinal  veins  are  also  found  to  be  dilated  and  tortuous,  there  may 
be  likewise  spontaneous  venous  pulsation,  or  this  may  be  produced  by 
slight  pressure  upon  the  eyeball. 

4.  Cloudiness  of  the  Aqueous  and  Vitreotos  Humours. — The  aqueous 
humour  is  often  found  slightly  but  uniformly  hazy,  rendering  the 
strvicture  of  the  iris  somewhat  indistinct,  and  causing  a  slight  change 
in  its  colour.  The  vitreous  humour  also  becomes  a  little  clouded,  but 
uniformly  so,  for  on  ophthalmoscopic  examination,  we  do  not  find  dark 
masses  floating  about  in  the  vitreous  humour,  but  only  a  diffused 
cloudiness,  which  renders  the  details  of  the  fundus  more  or  less  indis- 
tinct. This  haziness  of  the  humours  is  very  variable  in  its  degree  and 
duration,  sometimes,  it  is  so  slight  as  to  be  hardly  perceptible,  at  others, 
it  is  so  considerable  as  to  prevent  any  ophthalmoscopic  examination. 
In  the  majority  of  cases,  however,  it  is  but  moderate  in  the  premonitory 
stage.  It  may  come  on  several  times  a  day,  lasting  but  for  a  few  minutes 
at  a  time,  or  it  may  be  less  frequent,  or  of  longer  duration. 

5.  Dilatation  and  Sluggishness  of  the  Puj^il. — On  comparing  the 
pupil  of  the  eye  affected  with  premonitory  symptoms  of  glaucoma,  with 
that  of  the  other  (supposing  this  to  be  healthy),  the  former  will  be 
found  somewhat  dilated  and  sluggish,  reacting  but  slightly  on  the 
stimulus  of  light.  The  dilatation  is  never  so  considerable  as  in  the 
advanced  stages  of  glaucoma,  when  we  often  find  the  pupil  Avidely 
dilated  and  quite  immovable ;  its  sluggishness  is,  however,  generally 
well  marked. 

6.  Periodic  Dimness  of  Sight. — The  patient  is  troubled  by  occa- 
sional intermittent  dimness  of  sight.  At  such  times,  surrounding 
objects  appear  veiled  and  indistinct,  as  if  they  were  shrouded  in  a  grey 
fog  or  smoke.  The  degree  of  dimness  varies  considerably,  as  does  also 
the  duration  of  these  attacks ;  sometimes,  they  may  last  foi*  several 
hours,  at  others,  only  for  a  few  minutes.  At  such  a  time,  there  may 
also  exist  a  slight  contraction  of  the  field  of  vision  ;  generally,  however, 
there  is  only  indistinctness  of  eccentric  impressions  in  certain  direc- 
tions. Although  these  obscurations  may  be  due  to  transitory  cloudi- 
ness of  the  aqueous  and  vitreous  humours,  they  are  generally  caused 


462  GLAUCOMA. 

by  disturbances  in  the  circulation  of  the  eye.  The  character  of  these 
obscurations  may  be  imitated  by  pressure  upon  the  healthy  eye,  and 
Donders  has  found  that  the  dimness  of  vision  shows  itself  as  soon  as 
retinal  arterial  pulsation  is  produced  by  this  pressure  upon  the  eyeball. 
I  have  experimented  a  good  deal  upon  this  point,  and  have  arrived  at 
the  same  results.  I  have  also  found,  by  experiments  upon  myself,  that 
by  regulating  the  amount  of  pressure,  I  have  been  able  to  produce  any 
kind  of  obscuration,  from  the  slightest,  in  which  only  the  objects  lying 
quite  at  the  periphery  of  the  field  of  vision  appeared  somewhat  clouded, 
to  that  excessive  dimness  in  which  the  light  of  a  bright  lamp  was 
rendered  quite  unapparent.  The  increased  intra-ocular  pressure,  acting 
directly  upon  the  retina,  does  not,  therefore,  appear  to  be  so  much  the 
cause  of  these  obscurations  ;  but  we  must  seek  for  it  rather  in  the 
impairment  of  the  circulation,  the  stagnation  and  fulness  of  the  veins, 
and  pei'haps,  the  emptying  of  the  arteries.  The  increased  pressure 
produces  the  changes  in  the  circulation,  and  the  latter  cause  the 
obscurations.  The  truth  of  this  assertion  is  also  proved  by  the  fact 
that  these  attacks  of  dimness  are  generally  brought  on  by  anything 
that  causes  congestion  of  the  blood-vessels  of  the  eye — for  instance,  a 
full  meal,  great  excitement,  long- continued  stooping,  violent  exercise, 
etc. 

7.  The  appearance  of  a  Halo  or  Badnhoic  round  a  Ca.ndle. — This  is 
also  a  very  constant  symptom  of  the  premonitory  stage.  On  looking  at 
a  candle,  the  patient  sees  a  coloured  halo,  or  rainbow,  round  the  light. 
The  outer  side  of  the  ring  is  red,  the  inner  bluish-green.  This  has 
been  supposed  by  some  to  be  a  mere  physical  phenomenon,  due  to  a 
diffraction  (interference)  of  the  rays  of  light,  owing  to  some  change  in 
the  refractive  media,  especially  the  peripheral  portion  of  the  lens. 

It  is  seen  when  the  pupil  is  dilated,  but  disappears  when  the  patient 
is  directed  to  look  through  a  small  opening.  It  may,  however,  be  also 
dne  to  congestion  of  the  vessels,  for  I  have  seen  it  sometimes  brought 
on  by  stooping. 

8.  Ciliarij  Neuralgia,  i.e.,  pains,  more  or  less  acute,  in  the  forehead 
and  temples  and  passing  down  the  side  of  the  nose,  occur  occasionally 
at  an  early  period,  but  sometimes  only  at  a  later  part  of  the  premonitory 
stage,  at  the  same  time  with  the  intermittent  obscurations.  In  some 
instances  they  are,  however,  quite  absent. 

9.  The  field  o/ t;?'.s;o»  is  occasionally  somewhat  contracted;  generally, 
however,'  there  is  only  some  indistinctness  of  eccentric  impressions  in 
certain  directions,  more  particularly  if  the  illumination  is  but  moderate. 

The  intensity  of  these  symptoms  varies  with  the  severity  of  the 
attack.  They  may  be  so  slight  as  to  escape  all  observation,  or  they 
may  be  very  marked  if  the  attack  is  severe,  and  then  there  ai-e  often 
added  to  the  symptoms  above  enumerated,  diminution  in  the  size  of  the 


ACUTE   INFLAMMATORY  GLAUCOMA.  463 

anterior  chamber,  arterial  pulsation,  and  indistinctness  of  eccentric 
vision.  The  latter  symptom  may  be  absent  if  the  illumination  is  very 
bright,  but  becomes  evident  if  it  be  moderated. 

At  the  commencement,  these  premonitory  sjonptoms  only  show 
themselves  at  long  intervals,  of  perhaps  several  months,  but  gradually 
they  become  more  frequent.  At  first,  months  may  elapse  between 
each  attack,  then  weeks,  then  days,  and  when  they  occur  at  intervals 
of  a  few  days,  the  second  stage,  the  glaucoma  evolutum,  may  be 
expected,  although  this  may  even  occur  when  a  long  interval  exists. 
This  stage  may  also  be  suspected  as  close  at  hand,  if  the  premonitory 
symptoms  do  not  disappear  after  sleep,  even  of  short  duration  (Graefe). 
If  the  pei-iodic  attacks  no  longer  leave  behind  them  a  normal  pupil, 
and  a  normal  acuteness  of  vision,  still  more,  if  the  optic  nerve  is 
already  cupped,  we  must  no  longer  designate  it  as  the  premonitory 
stage,  but  as  a  case  of  glaucoma  evolutum,  with  periodic  increase  of 
the  symptoms. 

The  premonitory  stage  may  last  for  an  indefinite  period ;  years  may 
even  elapse  before  it  leads  to  confirmed  glaucoma ;  but  in  the  majority 
of  cases  it  does  not  extend  beyond  a  few  months,  or  it  may  pass  over 
into  glaucoma  even  after  the  second  or  third  attack,  there  being  only 
remissions,  and  not  clear  and  well  defined  intervals  between  the 
attacks.  Sometimes,  as  has  been  mentioned  above,  the  premonitory 
symptoms  are  so  slight  as  quite  to  escape  the  notice  of  the  patient,  par- 
ticularly if  the  other  eye  is  still  perfectly  healthy.  It  is  different, 
however,  where  one  eye  has  already  been  lost  by  glaucoma,  for  then  the 
patient's  attention  and  anxiety  are  at  once  aroused  by  any  of  the  pre- 
monitory symptoms,  and  he  early  consults  his  medical  attendant,  fearful 
lest  he  should  also  lose  the  sight  of  the  second  eye. 


In  the  gi*eat  majority  (about  75  per  cent.)  of  cases,  acute  inflam- 
matory glaucoma  is  preceded  by  a  more  or  less  marked  premonitory 
stage  of  varj-ing  duration.  The  intervals  between  the  premonitory 
attacks  become  less  and  less  frequent,  until  the  latter  recur  perhaps 
eveiy  two  or  three  days,  or  even  every  day.  The  patient  is  then 
suddenly  seized,  frequently  at  night  time  and  after  having  passed  per- 
haps several  sleepless  nights,  by  a  severe,  often  excruciating  pain  in  and 
around  the  eye,  wliich  extends  to  the  forehead,  temple,  and  down  the 
corresponding  side  of  the  nose,  as  far  as  the  extremity  of  the  bone. 
Sometimes  this  pain  extends  also  to  the  corresponding  half  of  the  head, 
and  even  to  the  occiput,  which  causes  it  often  to  be  mistaken  for  an 
attack  of  rheumatism.  At  the  same  time  there  may  be  considerable 
constitutional  disturbance,  febrile  excitement,  and  severe  nausea  and 
vomiting,   and  these  symptoms   may  be  of  such  prominence  that  the 


464  GLAUCOMA. 

patient  is  supposed  to  be  suffering  from  a  severe  bilious  attack,  and  the 
affection  of  the  eye  is  either  overlooked,  or  is  thought  to  be  dependent 
upon  this.  But  the  eye  shows  marked  symptoms  of  acute  internal 
inflammation.  The  eyelids  may  be  mtich  swollen,  red  and  pufiy.  The 
conjunctival  and  sub-conjunctival  vessels  are  injected,  the  veins  in  par- 
ticular being  dilated  and  gorged.  There  may  also  be  very  considerable 
serous  chemosis,  which  completely  hides  the  deeper  sub-conjunctival 
vascularity  and  the  rosy  zone  round  the  cornea.  There  is  also  much 
photophobia  and  lachrymation,  but  they  are  accompanied  by  very  little 
mucous  discharge,  and  this  chiefly  of  a  thin,  frothy  character.  The  cornea 
is  clouded  on  its  posterior  surface,  being  perhaps  studded  with  minute 
opacities,  deposited  from  the  aqueous  humour.  The  sensibility  of  the 
cornea  may  be  also  somewhat  diminished,  but  this  anaesthesia  never 
attains  the  same  degree  as  in  chronic  glaucoma,  where  it  is  often  so 
gTcat,  that  the  cornea  may  be  touched  or  even  rubbed  with  a  roll  of 
paper  or  the  brush  of  a  quill  pen,  without  its  being  felt.  Occasionally, 
the  anaesthesia  is  only  partial,  being  confined  to  a  certain  portion  of  the 
cornea.  This  loss,  or  diminution,  in  the  sensibility  is  due  to  the  com- 
pression of  the  nerves  supplying  the  cornea  by  the  increased  intra-ocular 
pressure,  as  is  proved  in  cases  of  acute  glaucoma,  where  the  sensibility 
at  once  returns  after  diminution  of  the  tension  by  iridectomy  or  para- 
centesis. The  sensibility  of  the  cornea  is  best  tested  by  touching  it 
delicately  with  a  finely-rolled  spill  of  silk  paper,  care  being  taken  to 
keep  the  eyelids  well  apart,  so  that  the  conjunctiva  is  not  touched.  In 
healthy  eyes,  the  cornea  is  so  exquisitely  sensitive  that  the  slightest 
touch  of  a  foreign  body  will  be  felt  and  resented. 

The  anterior  chamber  is  found  to  be  somewhat  more  shallow,  the 
iris  being  pressed  forward  and  even  perhaps  in  contact  with  the  cornea, 
the  aqueous  humour  is  clouded,  the  iris  somewhat  discoloured  and  of  a 
dirty  hue, — in  some  cases  there  may  even  be  acute  iritis,  with  deposits 
of  lymph  at  the  edge  of  the  pupil, — the  pupil  is  dilated  and  sluggish, 
and  in  elderly  people  a  peculiar  green  reflex  is  often  seen,  coming  appa- 
rently from  the  back  of  the  eye. 

It  has  already  been  stated  that  this  green  reflex  was  formerly  con- 
sidered as  the  principal  and  pathognomonic  symptom  of  glaucoma.  It 
is  due  to  the  following  cause  : — The  lens  undergoes  certain  physio- 
logical changes  after  the  age  of  forty,  amongst  others  assuming  a 
yellowish  tint.  I^ow  if  the  eye  of  an  elderly  person  (and  they  are  the 
most  prone  to  the  disease)  is  attacked  by  glaucoma,  the  aqueous  humour 
becomes  turbid  and  of  a  dirty,  bluish-grey  colour,  and  this  bluish-grey 
tint,  mixing  with  the  yellow  of  the  lens,  gives  rise  to  this  peculiar  green 
reflex.  The  latter  is  the  more  marked  on  account  of  the  dilatation  of 
the  pupil  which  exists  in  glaucoma,  as  more  light  is  thus  reflected 
from  the  lens,  more  particularly  its  pcrijjhery,  than  when  the  pupil  is 


ACUTE   INFLAMMATORY   GLAUCOMA.  4t)0 

of  the  normal  size.  The  greyish  haziness  of  the  vitreous  humour, 
moreover,  also  tends  to  increase  the  intensity  of  the  reflected  light. 
Two  facts  prove  that  this  is  the  true  explanation  of  this  green  reflex. 
1st.  If  the  anterior  chamber  is  tapped,  and  the  aqueous  huinour  flows 
off,  the  gTeen  reflex  at  once  disappears.  2nd.  If  a  youthful  eye  is 
attacked  by  glaucoma,  this  reflex  is  not  visible,  for  at  this  period  of 
life  the  lens  has  not  yet  acquired  a  yellow  tint,  and  in  such  a  case 
the  pupil  looks,  therefore,  only  of  a  dirty,  bluish-grey  colour. 

The  eyeball  will  be  fomid  abnormally  hard.  The  refractive  media 
are  generally  so  clouded  as  to  render  an  ophthalmoscopic  examination 
impossible.  If  they  are,  however,  sufficiently  clear  to  permit  of  the 
details  of  the  fundus  being  seen,  we  find  the  retinal  veins  dilated, 
tortuous,  and  perhaps  pulsating ;  the  optic  disc  may  be  slightly  red- 
dened or  of  a  dirty- yellow  appearance,  and  there  is  either  spontaneous 
arterial  pulsation,  or  this  may  be  readily  produced  by  slight  pressure 
on  the  eyeball.  In  the  first  attack  of  acute  glaucoma,  no  cupping  of 
the  optic  nerve  is  found,  for  this  only  occurs  when  the  increased 
tension  has  lasted  for  some  time.  We  also  occasionally  find  choroidal 
ecchynioses,  which  are  mostly  situated  at  the  equator  of  the  eye,  and 
generally  likewise  patches  of  retinal  ecchymoses,  chiefly  at  the  point 
of  division  of  the  retinal  veins.  These  are  particularly  seen  after  iridec- 
tomy, where  the  sudden  relief  of  tension  causes  a  rush  of  blood  through 
the  vessels  and  a  rupture  of  the  finer  capillaries. 

Vision  may  be  either  gTeatly  impaired,  so  that  the  patient  is  only 
able  to  distinguish  letters  of  the  largest  type  or  to  count  fingers,  or  it 
may  be  lost  completely  and  suddenly,  as  at  one  stroke,  being  diminished 
to  a  mere  quantitative  perception  of  light,  i.e.,  to  a  mere  distinction 
between  light  and  dark,  not  an  appreciation  of  coloui's  and  objects.  In 
some  very  severe  cases  even  this  is  lost.  The  field  of  vision  is  gene- 
rally somewhat  contracted,  often  concentrically.  The  patient  is  in  the 
most  cases  also  troubled  vnth  subjective  appearances  of  light,  balls  of 
fire,  showers  of  bright  stars,  etc. 

The  inflammatory  symptoms  may  gradually  subside,  but  the  blind- 
ness continue ;  this  is,  however,  very  exceptional.  In  most  cases,  the 
inflammatory  attack  passes  ofi' after  a  few  days  or  weeks,  having,  perhaps, 
undergone  during  this  time  several  remissions,  and  vision  may  be 
entirely  restored.  Such  a  temporary  recovery  may  occur  spontaneously, 
or  after  treatment  by  antiphlogistics,  mercury,  opium,  leeches,  etc. 
But  the  eye  does  not  return  to  its  normal  condition ;  the  anterior 
chamber  mostly  remains  somewhat  shallow,  the  iris  discoloured,  the 
pupil  dilated  and  sluggish,  the  field  of  vision  somewhat  contracted,  and 
the  tension  of  the  eyeball  more  or  less  augmented.  But  the  disease  is 
not  arrested.  The  acute  inflammatory  attacks  may  recur  again  and 
again,  leaving  the  sight  each  time  in  a  worse  condition,  and  the  visual 


4lJ6  GLAUCOMA. 

field  more  contracted,  until  the  sight  is  finally  completely  destroyed. 
In  other  cases,  no  farther  acute  inflammatory  attacks  occur,  but  chronic 
inflammatory  exacerbations  take  place.  Or  the  disease  may  progress 
insidiously,  without  any  apparent  recurrence  of  the  inflammatory 
symptoms.  The  eyeball  becomes  more  and  more  tense,  the  field  of  vision 
more  contracted,  often  to  a  sHt  shape,  the  sight  gradually  lost,  the 
fixation  perhaps  eccentric,*  the  cornea  roughened  and  anassthetic, 
the  anterior  chamber  very  small,  the  pupil  greatly  dilated  and  fixed, 
the  iris  discoloured,  atrophied,  and  shrivelled  up  to  a  narrow  rim, 
the  subconjunctival  veins  turgid  and  tortuous,  forming  loops  round  the 
cornea.  If  the  refractive  media  are  sufficiently  clear  to  permit  of  an 
ophthalmoscopic  examination,  we  then  find  that  there  is  a  progressive 
excavation  of  the  optic  nerve,  that  the  retinal  veins  are  dilated  and 
tortuous,  and  that  there  is  either  a  spontaneous  or  easily  producible 
arterial  pulsation.  We  not  unfi^equently  find,  even  after  the  disease 
has  thus  insidiously  run  its  course  without  any  inflammatory  exacer- 
bation since  the  first  acute  attack,  that  at  a  later  stage  these  inflamma- 
tory attacks,  even  of  a  very  acute  kind,  may  again  recur.  When 
the  disease  has  run  its  course,  and  all,  even  quantitative  percep- 
tion of  light  is  lost,  Von  Graefe  calls  it  glaucoma  consummatum, 
or  absolutum. 

Sometimes  we  meet  with  a  sitb-acute  form  of  glaucoma,  in  which 
all  the  inflammatory  symptoms  are  much  diminished  in  intensity ;  the 
pain  is  also  less,  nor  is  the  sight  so  much  impaired  as  in  the  acute 
cases. 

There  is  likewise  a  hsemorrhagic  form,  which  is  peculiarly  dangerous, 
as  it  is  far  less  favourably  influenced  by  iridectomy.  The  glauco- 
matous inflammation  sometimes  supervenes  upon  certain  haemorrhagic 
afiections  of  the  retina,  particularly  those  met  with  in  kidney  disease. 
In  these  cases  there  is  very  considerable  congestion  and  stagnation  of 
the  intra-ocular  circulation.  Now,  although  iridectomy  may  yield  some 
temporary  benefit,  yet  relapses  but  too  frequently  occur,  and  the  opera- 
tion is  occasionally  followed  in  this  form  by  great  intra-ocular  haemorr- 
hage, which  often  destroys  the  eye.  The  power  of  absorption  is  also 
very  much  impaired  in  these  cases,  for  we  find,  for  instance,  that 
haemorrhage  into  the  anterior  chamber  which  is  frequently  produced 
by  a  very  slight  cause,  such  as  a  fit  of  coughing,  etc.,  is  very  slowly 
and  imperfectly  absorbed. 

Von  Graefef  has  called  attention  to  a  class  of  cases  in  which  the 

*  By  the  term  centi'al  fixation  is  meant,  that  a  line  drawn  fi'om  the  object 
through  the  centre  of  the  cornea  of  the  observer  would  strike  his  yellow  spot ;  his 
optic  axis  being  in  fact  fixed  upon  the  object.  Eccentric  fixation,  therefore,  means 
that  some  other  portion  than  the  yellow  spot  is  directed  to  the  object,  having  retained 
more  sensibility  than  the  macula  lutea.  f  "  A.  f.  O.,"  viii,  2. 


CHRONIC  INFLAMMATORY  GLAUCOMA.  -Lt)7 

course  of  acute  glaucoma  is  most  I'apid,  so  that  the  sight,  even  all 
quantitative  perception  of  light,  of  a  previously  perfectly  healthy  eye,  may 
be  entirely  lost  within  a  few  hours,  or  even  within  half  an  hour,  of  Llio 
outbreak  of  the  disease.  He  has  termed  this  glaucoma  fidmlnaus. 
It  is,  however,  a  very  rare  form  indeed,  in  comparison  with  the  common 
acute  glaucoma. 

He  has  found  that  cases  of  glaucoma  fulminans  are  also  occasionally 
distinguished  by  a  very  rapid  development  of  the  other  symptoms  of 
increased  intra-ocular  pressure,  viz.,  intense  ciliary  neuralgia,  rapid  dila- 
tation of  the  pupil,  soon  reaching  its  maximum  extent,  rapid  diminution 
in  the  size  of  the  anterior  chamber,  anassthesia  of  the  cornea,  and  stony 
hardness  of  the  eyeball.  Sometimes,  however,  these  symptoms  are  not 
more  pronounced  than  in  the  common  form  of  acute  glaucoma,  and  yet 
the  sight  may  be  completely  destroyed  within  an  hour  or  two.  The 
phenomena  of  vascular  excitement  may  appear  simultaneously  with  the 
loss  of  sight,  but  they  occasionally  lag  behind  in  a  peculiar  manner. 
On  ophthalmoscopic  examination,  the  aqueous  and  vitreous  vsdll  be 
found  to  be  diflPusely  clouded,  but  if  they  are  sufficiently  clear  to  permit 
the  details  of  the  fundus  to  be  seen,  a  considerable  overfulness  of  the 
retinal  veins  will  be  observed.  Decrease  of  the  arteries  and  excavation 
of  the  optic  nerve  appear,  comparatively,  very  rapidly.  Von  Graefe 
has  in  one  case  noticed  the  latter  in  a  very  deep  form,  even  within 
a  few  weeks  after  the  outbreak  of  the  disease.  He  thinks  we  must 
assume  that,  in  this  form,  the  increase  in  the  tension  is  either  more 
considerable  or  more  sudden  than  in  the  ordinary  cases.  On  account 
of  the  great  stagnation  in  the  venous  circulation  of  the  eye  in  these 
cases,  iridectomy  is  often  followed  by  extensive  heemorrhage  into  the 
retina  and  choroid. 


2.— CHRONIC  INFLAMMATORY  GLAUCOMA. 

This  disease  may  be  insidiously  developed  from  the  premonitory 
stage.  The  premonitory  symptoms  become  more  frequent,  and  con- 
tinue for  a  longer  period ;  the  intermissions  are  of  less  duration,  until 
there  are  no  longer  any  distinct  intermissions,  but  only  remissions,  and 
the  disease  gradually  and  almost  imperceptibly  passes  over  into  chronic 
glaucoma ;  the  eye  assuming  the  same  condition  as  it  did  in  the  acute 
form,  after  the  conclusion  of  the  inflammatory  process.  It  becomes 
more  and  more  tense,  until  it  may  at  last  assume  a  stony  hardness 
(T.  3),  so  that  it  cannot  be  dimpled  by  even  a  firm  pressure  of  our  finger. 
The  subconjunctival  veins  become  dilated  and  tortuous,  the  sclerotic 
assuming  in  the  late  stages  of  the  disease  a  peculiar  waxy  hue,  which 
is  due  to  atrophy  of  the  subconjunctival  tissue,  and  to  a  diminution  in 

2  H  2 


468  GLAUCOMA. 

the  calibre  of  the  subconjunctival  arteries.  The  cornea  gradually  loses 
its  sensibility  more  and  more,  frequently,  however,  only  in  certain 
portions.  It  also  becomes  flatter.  The  anterior  chamber  becomes 
shallow,  the  aqueous  humour  clouded,  and  this  turbidity  may  change 
with  great  rapidity,  occurring,  perhaps,  several  times  a  day.  It  may 
be  produced  by  any  excitement  or  fatigue,  often  coming  on  after  a 
full  meal,  excessive  exercise,  etc.  The  iris  is  pushed  forward,  so  as  to 
be  perhaps  almost  in  contact  with  the  cornea.  It  is  dull  and  dis- 
coloured, its  fibrillae  being  more  or  less  obliterated,  and  not  showing  a 
clear  and  distinct  outline.  The  pupil  is  widely  dilated,  and  either 
immoveable  or  extremely  sluggish  on  the  stimulus  of  Hght.  The  field 
of  vision  becomes  greatly  contracted,  assuming,  perhaps,  a  slit  shape. 
As  has  been  before  pointed  out,  the  contraction  of  the  field  in  glaucoma 
begins,  as  a  rule,  at  the  inner  side,  extending  from  thence  upwards  and 
downwards,  so  that  the  outer  portion  is  the  last  to  become  affected. 
Vision  progressively  deteriorates,  the  fixation  often  becomes  eccentric, 
and  finally  the  sight  may  be  completely  destroyed,  so  that  not  even  a 
remnant  of  quantitative  perception  of  light  is  left,  even  although  the 
light  be  intensified  by  means  of  a  powerful  biconvex  lens.  On  ophthal- 
moscopic examination,  we  find  that  the  fundus  always  appears  more  or 
less  clouded,  often  to  such  an  extent  as  to  prevent  our  distinguishing 
the  details  of  the  background  of  the  eye.  This  haziness  is  due  to  opacity 
of  the  aqueous  and  vitreous  humours,  and  in  some  cases  also  of  the 
cornea  and  lens.  But  if  the  media  remain  sufficiently  clear  to  permit  of 
an  examination,  we  find  the  retinal  veins  widely  dilated  and  tortuous, 
the  arteries  diminished  in  calibre,  and  presenting  either  a  spontaneous 
or  easily  producible  pulsation ;  the  optic  nerve  more  or  less  deeply 
cupped,  and  the  vessels  displaced  at  its  periphery.  The  chief  and 
characteristic  difference  between  the  acute  and  the  chronic  inflammatory 
glaucoma  is,  that  the  latter  may  lead  to  even  complete  destruction  of 
sight,  without  any  symptoms  of  severe  inflammation  or  great  pain. 
There  may  only  be  insidious  attacks  of  chronic,  frequently  recurring 
inflammation,  leading  gradually  to  loss  of  sight.  At  first  these  inflam- 
matory attacks  may  be  intermittent,  occurring  at  considerable  intei'vals, 
whereas,  later  they  may  only  show  remissions.  In  other  cases  again,  after 
the  eye  has  been  suffering  for  some  time  from  these  insidious  chronic 
inflammations,  it  may  be  suddenly  attacked  by  a  severe  acute  exacer- 
bation, causing  very  great  pain  and  suffering.  These  acute  exacer- 
bations may  recur  again  and  again,  and  the  pain  may  be  so  severe  that 
recourse  must  be  had  to  an  iridectomy  for  its  relief,  even  although  there 
is  no  chance  of  restoring  any  sight.  In  such  instances,  the  jjatient 
and  his  friends  must  be  warned  beforehand  that  the  operation  is  not 
performed  for  the  sake  of  giving  any  sight,  but  only  in  order,  if  possible, 
to   relieve  the  pain.     In  many  cases,  particularly  if  the  iridectomy  be 


CHRONIC   INFLAMMATORY   GLAUCOMA.  469 

made  sufRcientlj  large,  the  relief  may  be  permanent ;  in  others,  it  is 
only  temporary.  When  speaking  of  acute  glaucoma,  it  was  mentioned 
that  after  the  first  acute  attack,  the  disease  might  gradually  pass  over 
into  chronic  inflammatory  glaucoma,  no  fresh  acute  attack  occuri-ing, 
but  only  ckronic,  latent,  inflammatory  exacerbations.  Sometimes  the 
course  of  chronic  glaucoma  is  so  insidious  that  the  sight  of  the  eye 
may  be  completely  lost  without  the  patient  being  aware  that  anything 
was  the  matter  with  his  eye,  the  other  being  well.  Perchance  he  closes 
the  good  eye,  and  then  discovers  the  blindness  of  the  other,  and  thus 
often  supposes  the  vision  to  have  been  suddenly  lost.  On  being 
questioned,  he  may  remember  that  he  occasionally  experienced  slight 
pain  in  and  around  the  eye,  which  he  supposed  to  be  rheumatic  ;  that  it 
occasionally  became  somewhat  reddened,  and  watered  a  little,  which 
was  attributed  to  a  cold ;  but  otherwise  he  noticed  nothing  peculiar. 
This  may  not  only  occur  amongst  the  humbler  classes,  following 
pursuits  which  require  but  little  employment  of  sight  in  reading,  etc., 
as  amongst  labourers  ;  but  it  may  even  happen  amongst  men  of  literary 
habits  and  avocations,  employed  for  many  hours  daily  in  reading  and 
wi'iting. 

When  the  disease  has  run  its  course,  and  all  sight  is  lost.  Von 
Graefe  terms  it  glaucoma  absolutum.  Then  any  chance  of  benefiting 
the  sight  by  an  operation  is  past.  The  lens  frequently  becomes  opaque, 
assuming  the  peculiar  greenish  hue  so  characteristic  of  glaucomatous 
cataract.  The  glaucoma  absolutum  may  exist  for  a  length  of  time 
without  the  eye  undergoing  any  changes,  except  that  atrophy  of  the 
iris,  choroid,  and  optic  nerve  become  more  and  more  apparent.  In  other 
cases,  frequent — often  very  acute  and  violent — inflammatory  symptoms 
show  themselves,  accompanied  by  intense  ciliary  neuralgia  and  head- 
ache. In  the  last  stages  of  the  disease  other  changes  occur ;  the  iris 
becomes  reduced  to  a  narrow  streak,  the  cornea  opaque  and  softened, 
more  particularly  in  its  central  portion,  and  haemoiThagic  eflusions 
take  place  into  the  anterior  chamber,  the  vitreous  humour,  and  the  inner 
tissues  of  the  eyeball.  Sclerotic  staphylomata  are  formed,  and  suppu- 
rative inflammation  may  even  occur,  leading  to  atrophy  of  the  globe. 
Von  Graefe  calls  this  the  stage  of  glaucomatous  degeneration.  In  it, 
iridectomy  no  longer  proves  a  sure  remedy  for  the  inflammatory  com- 
plication. Generally  the  sight  is  completely  lost.  Sometimes  the  one 
eye  may  be  lost  from  chronic  inflammatory  glaucoma,  or  from  the  appa- 
rently non-inflammatory  form  (glaucoma  simplex),  and  the  other  be 
attacked  by  acute  glaucoma. 


470  GLAUCOMA, 


3.— GLAUCOMA  SIMPLEX  (BONDERS).* 

This  disease  was  for  a  long  time  considered  as  distinctive  from 
glaucoma,  with  which  it  was  supposed  to  have  nothing  in  common  but 
the  excavation  of  the  optic  nerve.  Von  Graefe  described  it  first  under 
the  title  of  "  Amaui^osis  with  excavation  of  the  optic  nerve."  But  he 
has  now  also  admitted  it  into  the  glaucomatous  group  of  diseases. 

The  course  of  the  disease  is  often  exceedingly  insidious,  so  that  it 
may  be  considerably  advanced  before  the  patients  pay  any  particular 
attention  to  it,  supposing,  but  too  frequently,  that  the  increasing  weak- 
ness of  sight  is  simply  owing  to  old  age.  Though  this  impairment  of 
vision  may  be  noticed  also  for  distance,  it  makes  itself  particularly  felt 
in  reading,  writing,  sewing,  etc.,  and  convex  glasses  are  found  but  of 
slight  assistance.  There  is  generally  no  premonitory  stage,  for  the 
intermittent  obscurations,  rainbows  round  a  candle,  etc.,  are  mostly 
due  to  some  slight  inflammatory  attack,  accompanied  by  cloudiness  of 
the  refractive  media. 

The  external  appearance  of  the  eye  may  be  perfectly  healthy.  The 
refractive  media  may  be  quite  clear,  the  cornea  sensitive,  the  anterior 
chamber  of  the  normal  size,  the  iris  healthy  and  not  discoloured,  or  but 
very  slightly  so,  this  being  only  apparent  on  comparison  with  the  iris 
of  the  other  healthy  eye ;  the  pupil  perhaps  slightly  dilated  and  a  little 
sluggish.  But  the  eyeball  is  generally  found  to  be  abnormally  tense, 
and  with  the  ophthalmoscope,  we  observe  that  the  optic  nerve  shows  a 
glaucomatous  excavation.  Sometimes  this  increase  in  tension  varies 
greatly,  being  very  marked  at  one  time,  and  hardly,  if  at  all,  apparent 
at  another ;  it  is  of  great  consequence,  therefore,  to  examine  such  eyes 
frequently,  and  at  different  periods  of  the  day.  There  is  still  a  good 
deal  of  discrepancy  of  opinion  as  to  the  invariable  presence  of  increased 
tension  of  the  eyeball  in  this  form  of  glaucoma.  Some  assert  that 
tension  is  always  increased  in  all  cases  of  glaucoma  simplex ;  others, 
again,  think  that  although  this  undoubtedly  does  occur  in  the  majority 
of  cases,  yet  that  in  others  it  is  absent.  Von  Graefe,  in  particular, 
maintains  that  the  intra-ocular  tension  is  not  in  all  cases  increased  in  a 
marked  manner.  He  thinks  that  the  occurrence  of  glaucomatous 
excavation  of  the  optic  nerve,  without  any  marked  increase  in  the 
tension  of  the  eyeball,  may  be  explained  thus : — That  perhaps  the 
resisting  power  of  the  optic  papilla  varies  in  different  individuals,  per- 
haps also  at  different  ages.  Just  as  iritis  and  iridocyclitis  serosa  may 
occasionally  be  observed,  particularly  in  young  individuals,  to  exist  for 
some  length  of  time  with  an  unmistakeable  increase  of  tension,  without 

*  Haffmann,  "  ArclliA^"  viii,  2. 


GLAUCOMA  SIMPLEX.  471 

any  excavation,   may  not,   on   the  other  hand,  the  power  of  resistance 
of  the  optic  papilla  be  absolutely  (?)  or  relatively  so  diminished,  that  an 
exceedingly  slight  increase  of  tension,  not  exceeding  the  normal  range 
of  variation  of  tension,  may  already  cause  an  excavation  ?     But  every, 
even  the  most  considerable  increase  of  tension,  requires   to  act  some 
time  before  it  leads  to  cupping.     Tlie  truth  of  this  is  shown  in  cases  of 
acute  glaucoma,   where  there  is  no   cup  directly  after  the  first  acute 
attack,  although  this  may  have  lasted  for  some  weeks,  during  which 
the  intra-ocular  pressure  was  greatly  increased.     In  glaucoma  fulminans 
it  is  somewhat  different,  for  there  it  appears  to  supervene  early.     But  a 
long-continued,   though  slight,  increase  of  tension  will  lead  gradually 
to  an  excavation  of  the  optic  nerve,  which  increases  more  and  more  in 
depth ;    the  vessels  then  become  interrupted  at  its  edge,  and  there  is 
spontaneous  or  easily  producible  arterial  pulsation.     The  veins  appear 
dilated,  and  perhaps  somewhat  tortuous.     If  the  tension  continues,  the 
optic    nerve  gradually  atrophies,  the   arteries   become  diminished  in 
calibre,  and  complete  blindness  may  supervene.     It  is  found  that  if  the 
increase  in  tension  is  very  slow  and  gradual,  the  excavation  of  the  optic 
nerve  may  become  very  considerable  in  depth,  Avithoutthe  sight  or  field 
of  vision  being  markedly  impaired.     Increased  intra-ocular  tension  is, 
therefore,  generally  the  first  symptom  of  glaucoma  simplex,  being  accom- 
panied perhaps  by  a  relatively  rapid  increase  of  presbyopia,  and  some 
hypermetropia ;    gradually,  however,  the  optic  nerve  becomes  cupped, 
and  these  symptoms  may  last  for  a  considerable  time  without  others 
supervening.     In  some  cases,  however,  the  augmented  tension  may  exist 
for  a  long  period  without  the  presence  of  other  glaucomatous  symptoms. 
Occasionally,  glaucoma  simplex  may  run  its  course,  even  to  complete 
blindness,  without   the   appearance    of  any  inflammatory  symptoms. 
The  disease  slowly,  but  surely,  progresses,  the  eyeball  becomes  more  and 
more  hard,  the  cornea  anaesthetic,  the  anterior  chamber  narrower,  the 
vessels  more  turgid  and  congested,  the  pupil  dilated  and  sluggish,  the 
retinal  veins  gorged,  the  arteries   diminished  in  calibre,  and  perhaps 
pulsating,  the  optic  nerve  deeply  cupped  and  whitish  in  colour,  the 
visual  field  more  and  more  contracted,  and  the  sight  finally  destroyed. 
But  in  the  majority  of  cases,  inflammatory  symptoms  show  themselves 
during  the  progress  of  the  disease,  and  these  may  assume  an  acute,  a 
chronic,  or  an  intermittent  type.     They  present  the  same  character 
as   in   acute   or   chronic   inflammatory   glaucoma ;    rapid    diminution 
of  vision,   obscurations,  rainbows   round    a    candle,    augmentation  of 
tension,   dullness  of  the  aqueous  and  vitreous    humours,  etc.     Some- 
times, however,  these  inflammatory  symptoms  may  not  appear  until  the 
disease  has  long  run  its  course,  and  the  sight  has  been  completely  lost. 
In  other  cases,  they  may  be  so  transitory  as  to  escape  our  observation, 
and  their  previous  existence  may  not  be  ascertained,  except  by  a  very 


472 


GLAUCOMA. 


close  examination  into  the  history  of  the  ease.  Where  manifest  symp- 
toms of  inflammation  are  apparently  wanting  in  a  case  of  glaucoma 
simplex,  the  condition  of  the  other  eye,  if  healthy,  should  be  ascertained  ; 
and  then,  on  a  comparison  of  the  two,  we  may  often  detect  slight 
changes  in  the  colour  and  structure  of  the  iris,  and  slight  haziness  of 
the  aqueous  humour  of  the  afiected  eye,  which,  but  for  this  comparison, 
would  have  escaped  our  attention.  Von  Graefe  also  points  out  the 
necessity  of  examining  such  patients  at  a  period  of  the  day  most  favour- 
able for  the  observance  of  any  inflammatory  symptoms,  and  calls 
attention  to  the  important  fact,  that  whilst  the  inflammatory  symptoms, 
particularly  the  deeper  injection,  become  commonly  more  apparent 
soon  after  sleep,  the  reverse  obtains  in  glaucoma,  for  here  they  become 
the  more  prominent  the  longer  the  patient  keeps  awake,  more  particu- 
larly if  he  remains  up  beyond  his  customary  time  for  retiring  to  bed. 
He  mentions  an  interesting  case,  illustrative  of  the  peculiar  transitory 
character  which  the  inflammatory  symptoms  may  occasionally  assume. 
The  right  eye  of  the  patient  in  question  ordinarily  presented  a  perfectly 
healthy  appearance,  but  for  several  years  past,  it  assumes  a  well-marked 
glaucomatous  condition  when  he  has  been  playing  cards  for  some  length 
of  time,  and  only  then.  On  such  occasions,  the  anterior  chamber  be- 
comes shallower,  the  aqueous  humour  difiusely  clouded,  the  pupil  some- 
what dilated  and  sluggish,  the  retinal  veins  dilated,  particularly  towards 
the  edge  of  the  optic  disc,  and  arterial  pulsation  may  be  produced  by 
the  faintest  pressure  upon  the  eyeball ;  together  with  these  symptoms, 
there  is  indistinctness  of  vision,  surrounding  objects  appearing  to  be 
covered  by  a  veil  or  cloud.  Not  till  the  following  morning  have  all 
these  symptoms  disappeared,  then  the  sight  is  again  normal  (No.  1  of 
Jager's  types  at  12  inches),  and  the  increase  in  the  tension  of  the 
eyeball,  which  was  very  manifest  during  the  attack,  is  no  longer 
appreciable.  We  often  find  in  glaucoma  simplex,  that  the  second  eye 
becomes  affected  soon  after  the  disease  has  manifested  itself  in  the 
other ;  it,  moreover,  often  attacks  myopic  eyes.  In  both  of  these 
points  it  differs  materially  from  the  majority  of  cases  of  inflammatory 
glaucoma. 

Haffmann  considers  that  glaucoma  simplex  is  identical  with  the 
premonitory  stage  of  glaucoma  of  Von  Graefe,  and  maintains  that  all 
the  symptoms  enumerated  as  existing  in  the  premonitory  stage,  are 
present  in  glaucoma  simplex ;  but  I  think  it  of  the  greatest  practical 
importance  to  maintain  the  existence  of  a  premonitory  stage,  for  we 
find,  after  all,  that  its  covirse  is  generally  very  different  from  that  of 
glaucoma  simplex.  The  premonitory  stage  may  exist  even  for  many 
years  without  producing  any  glaucomatous  changes  in  the  eye,  the 
symptoms  may  only  show  themselves  at  long  intervals,  and  in  their 
intermissions  the  eye  may  be  perfectly  healthy ;  or  they  may  recur  at 


OPHTH.VLMOSCOPIC   SYMPTOMS   OF   GLAUCOMA.  47  ?> 

more  frequent  intervals,  and  pass  over  into  acute  or  chronic  glaucoma. 
In  other  cases,  they  may  pass  over  into  developed  glaucoma  after  only 
a  few  premonitory  attacks.  Besides  this,  we  find  that  the  most 
brilliant  results  of  iridectomy  are  to  be  expected  in  the  premonitory 
stage  ;  but  this  is  by  no  means  the  case  in  glaucoma  simplex. 

4.— SECONDARY  OR  CONSECUTIVE  GLAUCOMA. 

"We  find  that  certain  diseases  of  the  eye  may  in  their  progress 
become  complicated  with  glaucoma,  the  eye  then  presenting  glauco- 
matous symptoms  superadded  to  those  of  the  original  disease.  This 
complication  may  especially  occur  in  the  following  diseases,  viz.,  1, 
iritis ;  2,  sclerotico-choroiditis  posterior ;  3,  traumatic  cataract ;  4, 
prominent  cicatrix  of  the  cornea  (anterior  staphyloma)  ;  5,  dislocation 
of  the  lens.  A  fuller  account  of  this  subject  will  be  found  in  the 
difierent  ai-ticles  upon  these  diseases.* 

But  glaucoma  may  also  complicate  diseases  which  stand  in  no 
causal  relation  to  it.  Thus  it  niay  supervene  upon  common  senile 
cataract,  or  upon  cerebral  amaurosis.  In  the  former  case,  the  cataract 
should  never  be  removed  at  the  same  time  that  the  iridectomy  is  made 
for  the  glaucoma,  for  this  will  greatly  increase  the  danger  of  intra- 
ocular hgemorrhage,  on  account  of  the  sudden  diminution  of  the  tension. 
Some  months  should  elapse  between  the  two  operations,  in  order  that 
the  improvement  in  the  circulation,  tension,  and  nutrition  of  the  eye 
may  have  become  thoroughly  established. 

5.— OPHTHALMOSCOPIC  SYMPTOMS  OF  GLAUCOMA. 

The  characteristic  ophthalmoscopic  symptoms  of  glaucoma  are — 
pulsation  of  the  central  vessels  of  the  retina,  and  excavation  of  the 
optic  nerve  (vide  p.  390). 

The  stasis  in  the  venous  circulation  of  the  retina  is  often  very 
considerable,  the  veins  are  dilated  and  tortuous,  the  smaller  veinlets 
assuming  a   corkscrew  appearance ;   if  the  stasis  be  very  great,  the 

*  It  is  an  interesting  fact  that  glaucoma  may  also,  in  rare  instances,  become 
developed  in  an  eye  in  which  the  lens  is  absent,  and  this,  as  has  been  pointed  out  by 
Kydel  ("  Bericht  iiber  die  Wiener  Augenklinik,"  p.  155),  is  an  important  point  with 
regard  to  the  theory  that  the  beneficial  effect  of  the  iridectomy  in  glaucoma  is  due 
to  its  relief  of  the  irritation  and  teazing  of  the  iris,  which  occur  when  the  latter 
together  with  the  lens,  is  pressed  forwards  owing  to  the  increased  intra-ocular  ten- 
sion. Now,  in  two  cases  of  glaucoma  in  eyes  without  a  lens,  the  anterior  chamber 
was  deep  and  the  iris  lying  in  its  normal  plane,  so  that  there  could  be  no  question 
of  its  being  teazed  or  irritated  by  pressure.  Heymann  also  reports  some  cases  of 
glaucoma  becoming  developed  in  eyes  in  which  the  lens  was  absent  ("  Kl.  Monats.," 
1867). 


474  GLAUCOMA. 

larger  venous  brandies  may  even  show  peculiar  bead-like  swellings. 
This  is,  however,  very  rare.  I  have  seen  one  case  in  which  there  was 
a  distinct  tendency  to  these  swellings,  but  Liebreich  figures  a  case,  in 
his  "  Atlas  d' Ophthalmoscopic"  in  which  it  existed  in  the  most  marked 
manner.  After  diminution  of  the  pathological  increase  in  the  intra- 
ocular pressure,  the  stagnation  in  the  venous  circulation  ceases,  the 
calibre  of  the  veins  diminishes  in  size,  and  they  lose  their  tortuosity. 
For  instance,  after  the  performance  of  iridectomy,  and  the  consequent 
diminution  in  the  tension  of  the  eyeball,  we  frequently  have  an  oppor- 
tunity of  observing  the  change  in  the  venous  cii'culation.  Thus,  extensive 
retinal  ecchymoses  are  perhaps  met  with,  and  the  veins,  which,  before 
the  operation,  were  very  dilated  and  swollen,  are  now  much  diminished 
in  size  and  paler.  The  retinal  arteries  in  glaucoma  appear  very  thin 
and  small,  and  much  paler  than  in  the  normal  eye. 

Whilst  spontaneous  venous  pulsation  (vide  p.  308)  may  occur  in 
normal  eyes,  spontaneous  arterial  pulsation  is  only  observed  if  the 
intra-ocular  tension  is  markedly  increased.  The  arterial  pulsation  is 
synchronous  with  the  radial  pulse,  but  slightly  later  than  the  carotid 
pulsation.  It  is  confined  to  the  disc,  and  presents  a  rapid  to-and-fro 
movement,  and  a  rhythmical  filling  and  emptying  of  the  arteries. 
The  arterial  diastole  takes  less  time  than  the  systole,  and  is  charac- 
terised by  a  rapid,  jerky  entrance  of  a  column  of  blood  into  a  pre- 
viously empty  vessel. 


C— ON  THE  NATURE  AND  CAUSES  OF  THE  GLAUCO- 
MATOUS PROCESS. 

The  true  nature  and  cause  of  the  glaucomatous  process  are  still 
involved  in  some  obscurity  and  doubt.  In  the  great  majority  of  cases 
of  glaucoma  there  are  marked  inflammatory  symptoms,  but  it  must  be 
freely  admitted  that  we  do  sometimes,  although  far  more  rarely,  meet 
with  cases  of  glaucoma  simplex,  in  which  no  inflammatory  symptoms 
can  be  detected.  Indeed  it  is  the  latter  fact  which  causes  all  the  diffi- 
culty, for  we  can  easily  explain  the  increased  tension,  and  all  the 
symptoms  which  follow  in  its  train,  as  due  to  an  inflammatory  origin ; 
but  we  cannot  as  satisfactorily  explain  what  constitutes  the  primary 
cause  of  the  increased  tension  in  glaucoma  simplex,  which  leads  to  the 
gradual  loss  of  sight  from  excavation  and  degeneration  of  the  optic 
nerve  without  any  apjDearance  of  inflammation.  In  the  inflammatory 
forms  of  glaucoma,  the  seat  of  the  inflammation  is  chiefly  in  the  uveal 
tract,  the  choroid,  ciliary  body,  and  the  iris.  But  other  structures, 
such  as  the  cornea,  sclerotic,  and  retina  may  subsequently  become 
involved.     This  irido-choroiditis  causes  an  increase  of  serosity,  more 


NATURE  AND  CAUSES  OF  THE  GLAUCOMATOUS  PROCESS.   475 

especially  in  the  vitreous  humour,  and  an  augmentation  of  the  intra- 
ocular tension ;  the  latter  giving  rise  to  all  the  glaucomatous  symp- 
toms described  above.  Together  with  this  increase  in  the  volume  of 
the  vitreoiis  humour,  there  exists  in  glaucoma  a  diminution  in  the  power 
of  absorption,  and  this  may  explain  why  these  serous  effusions  are 
not  removed,  as  in  other  forms  of  choroiditis,  by  an  increased  activity 
of  the  absorbents.  Attention  has  been  called  by  some  writers  to  the 
fact,  that  the  sclerotic  appears  pecuUarly  rigid  and  unyielding  in  glau- 
coma, and  it  has  been  supposed  that  this  is  not  unfrequently  congenital 
or  hereditary,  and  may  form  a  predisposing  element  to  glaucoma. 
Now,  if  such  an  abnormal  rigidity  of  the  sclerotic  exists,  we  can  easily 
understand  how  any  rapid,  though  slight,  augmentation  in  volume  of 
the  contents  of  the  eyeball,  must  not  only  give  rise  to  a  dispropor- 
tionate increase  in  the  intra-ocular  pressure,  but  must  also  augment 
the  tendency  to  stagnation  in  the  blood-vessels.  Coccius  has  found  in 
a  case  of  glaucoma  that  the  sclerotic  had  undergone  fatty  metamor- 
phosis, and  he  thinks  that  the  affection  of  the  sclerotic  mayperhaps 
have  been  the  cause  of  the  increased  intra-ocular  tension.  There  can 
be  no  doubt  that  the  rigidity  of  the  sclerotic  plays  a  very  important 
part  in  glaucoma.  For  we  find  that  in  youthful  individuals,  in  whom 
the  sclerotic  is  more  elastic  and  yielding,  an  increase  of  the  intra-ocular 
tension  dependent  upon  some  inflammation  of  the  uveal  tract  may 
exist  for  some  time  without  exerting  any  deleterious  efi'ect  upon  the 
optic  nerve  or  retina.  The  sclerotic,  perhaps,  yields  a  little  as  a  whole 
before  this  increased  tension  and  adapts  itself  to  it,  or  it  may  become 
slightly  bulged  at  a  certain  point ;  whereas,  in  older  persons,  in  whom 
the  sclerotic  is  more  firm,  rigid,  and  unyielding,  the  existence  of  an 
increase  in  the  intra-ocular  tension  is  much  more  dangerous,  for  it 
soon  causes  the  least  resistant  tissue  (in  this  case  the  optic  nerve)  to 
yield  before  it,  and  become  excavated. 

When  considering  the  difierent  forms  of  glaucoma,  we  had  frequent 
occasion  to  point  out  the  great  variations  in  the  intensity  of  the  inflam- 
matory symptoms.  We  saw  that  in  acute  glaucoma,  the  inflammation 
might  be  very  severe  during  the  first  attack,  but  that  after  its  sub- 
sidence, the  inflammatory  exacerbations  might  assume  an  insidious 
chronic  character,  and  the  disease  gradually  pass  over  into  glaucoma 
absolutum,  without  the  recurrence  of  any  acute  attack.  Again,  that  in 
the  chronic  form  the  inflammatory  symptoms  might,  at  the  outset,  be 
but  little  marked,  but  that  in  the  course  of  the  disease  acute  exacer- 
bations, even  of  a  very  severe  character,  might  show  themselves.  In 
the  third  form  (glaucoma  simplex),  it  was  stated  that  the  disease  might 
occasionally  run  its  course  without  the  apparent  occurrence  of  any 
inflammatory  symptoms — the  eyeball  becoming  stony  hard,  the  optic 
nerve  deeply  excavated,  the  sight  destroyed — but  the  refractive  media 


476  GLAUCOMA. 

remaining  perfectly  clear.  But  in  the  vast  majority  of  cases  of  glaucoma 
simplex,  inflammatory  symptoms,  of  varying  severity,  do  show  them- 
selves during  the  pi-ogress  of  the  disease.  Now,  on  account  of  the 
fact  that  glaucoma  simplex  may  occasionally  run  its  course  without  the 
apparent  presence  of  any  inflammatory  symptoms,  and  on  account  of 
the  increased  tension  being  sometimes  the  first  manifest  symptom  of 
the  disease,  it  has  been  supposed  by  Donders  that  the  inflammation  is 
not  the  integral  part  of  the  glaucomatous  process,  but  only  a  compli- 
cation, which,  though  occurring  in  the  majority  of  cases,  need  not 
necessarily  be  always  present.  He  considers  the  increase  in  the  inti'a- 
ocular  tension  as  the  essence  of  the  disease,  and,  therefore,  the  glau- 
coma simplex,  which  runs  its  coui'se  without  any  inflammatory  symptoms, 
as  the  primordial  type  of  the  disease ;  and  he  thinks  that  the  acute  or 
chi'onic  inflammation  which  shows  itself  in  the  majority  of  cases  of 
glaucoma  is  but  a  comphcation,  which  is  of  secondary  importance,  and 
not  necessary  to  the  glaucomatous  process.  He,  therefore,  speaks  of 
glaucoma  simplex,  and  glaucoma  cum  ophthalmia.  The  anomaly  in 
the  secretion  of  the  fluids  of  the  eye  he  thinks  due  to  an  abnormal 
irritation  of  the  nerves  regulating  the  intra-ocular  secretion.  Now 
from  some  very  interesting  and  ingenious  experiments  made  by 
Dr.  Wegner  (A.  f.  O.,  xii,  2,  1),  it  appears  certain  that  the  vaso- 
motor nerves  of  the  iris,  and  in  all  probability  those  of  the  choroid 
also,  are  furnished  by  the  sympathetic.  He  found  in  experiments  upon 
rabbits  that  a  division  of  the  sympathetic  in  the  neck  leads  to  a  dila- 
tation of  the  vessels  of  the  iris  and  choroid,  and  a  diminution  of  the 
intra-ocular  pressure.  It  may  consequently  be  assumed  that  irritation 
of  the  vaso-motor  nerves  would  produce  an  increase  in  the  intra-ocular 
pressure.  But,  as  Wegner  states,  the  latter  experiment  is  extremely 
difficult  and  uncertain,  on  account  of  the  impossibility  of  regulating 
the  degree  of  irritation  with  sufficient  delicacy.  The  intimate  relation 
between  the  branches  of  the  fifth  supplying  the  eyeball  and  the  sympa- 
thetic, easily  explains  how  an  irritation  of  the  former  may  be  reflected 
to  the  sympathetic,  and  thus  cause  an  hypersecretion  of  fluid  within  the 
eye,  and  an  increase  in  the  intra-ocular  pressure.  In  this  way  the  cases 
of  glaucoma  simplex  are  readily  explained.  Such  cases  have  been 
observed  by  Hutchinson*  and  Horner.f  In  one  case  of  Horner's,  the 
attacks  of  neuralgia  were  simultaneously  accompanied  by  glaucomatous 
symptoms.  From  these  facts  we  might  certainly  venture  upon  the 
hypothesis,  that  in  glaucoma  simplex  som.e  extra-ocular  irritation  of  the 
sympathetic  gives  rise  to  the  hypersecretion  of  fluid  and  increase  of 
tension  within  the  eye.  At  present,  however,  it  must  be  admitted  that 
these  questions  demand  still  further  investigation  for  their  satisfactory 
solution. 

*  "  R.  L.  O.  H.  Rep.,"  iv  and  v.  f  "A.  f.  O.,"  xii,  2. 


NATURE  AND  CAUSES  OF  THE  GLAUC0MAT(3US  PROCESS.   477 

It  has  also  been  urged  that  inflammatory  glaucoma  (glaucomatous 
ophthalmia)  cannot  occur  primarily  in  a  hitherto  healthy  eye,  that  an 
increase  in  the  tension  of  the  eyeball  pre-existed ;  that,  in  fact,  glau- 
coma simplex  had  existed,  perhaps  quite  unknown  to  the  patient,  and 
that  the  inflammation  supervened  upon  this.  But  we  sometimes  meet 
with  cases  of  acute  glaucoma  in  which  there  was  no  trace  of  increased 
tension,  or  any  other  glaucomatous  symptom,  prior  to  the  outbreak  of 
the  disease.  Thus  Von  Graefe  mentions  cases  in  which  he  has  ope- 
rated for  glaucoma  upon  the  one  eye,  the  other  being  at  the  time  of 
operation  of  quite  a  normal  degree  of  tension ;  and  yet  the  latter  was 
soon  after  attacked  by  glaucoma,  in  one  case  even  by  glaucoma  fulminans. 
He  thinks,  moreover,  that  the  mere  increase  of  tension  should  not  be 
allowed  to  constitute  a  premonitory  stage,  for  even  a  considerable 
increase  of  tension  may  exist  for  an  indefinite  period  without  the 
appearance  of  other  glaucomatous  symptoms.  In  families  in  which 
glaucoma  is  hereditary,  an  increased  resistance,  often  of  a  marked 
degree,  exists  even  in  infancy,  and  the  disease  may  not  show  itself  till 
middle  age,  or  even  not  at  all. 

The  question  whether  the  inflammation  be  but  of  secondary  import- 
ance or  not,  is  one  of  much  consequence.  The  great  difficulty  lies  in 
those  cases  (although  they  are  but  rare)  in  which  we  find  the  glaucoma- 
tous disease  running  its  coui'se  without  any,  even  the  slightest  symptom 
of  inflammation ;  for  if  this  be  possible,  then,  indeed,  we  cannot  look 
upon  the  inflammatory  symptoms  as  the  sine  qua  non  of  the  disease.  In 
such  cases  we  might,  perhaps,  venture  upon  the  hypothesis  that  an 
extra-ocular  irritation  of  the  sympathetic  was  the  cause  of  the  glaucoma. 
But  at  present  we  have  no  certain  proofs  to  rely  upon.  Von  Gi-aefe 
maintains  the  inflammatory  nature  of  glaucoma,  accompanied  by  an 
increased  secretion  of  the  fluids  of  the  eye,  and  by  augmented  tension. 
He  thinks  that  in  the  cases  of  glaucoma  simplex  a  lengthened  obser- 
vation will  generally  show  us  that  transitory  inflammatory  exacerbations 
(perhaps  of  a  very  ephemeral  nature)  do  mostly  occur.  Such  exacer- 
bations may  be  but  very  slightly  marked,  and  easily  escape  the  attention 
of  the  patient  or  his  medical  attendant ;  or  they  may  only  occui-  at 
certain  periods,  or  be  produced  only  by  certain  causes,  as,  for  example, 
in  the  case  mentioned  above,  iu  which  they  only  came  on  whenever  the 
patient  played  at  cards.  The  absence  of  any  externally  visible  symp- 
toms of  vascularity  is  no  proof  of  the  non-existence  of  internal  inflam- 
mation, for  the  ophthalmoscope  constantly  reveals  to  us  the  presence 
of  even  considerable  inflammation  of  the  choroid  and  retina,  without 
the  existence  of  any  increased  vascularity  of  the  external  tunics  of  the 
eyeball.  The  haziness  of  the  aqueous  and  vitreous  humoui-s,  which 
may  arise  during  such  an  ephemeral  exacerbation,  may  likewise  be  so 
slight  and  delicate  as  to  escape  detection  with  the  ophthalmoscope,  for 


478  GLAUCOMA. 

we  know  that  fine  diffuse  opacities  of  tlie  aqueous  humour  arc  often 
quite  invisible  by  transmitted  light.* 

Glaucoma  is  a  disease  of  old  age.  It  is  most  frequently  met  with  be- 
tween the  ages  of  50  and  60,  but  may  occm"  even  at  a  mtich  later  period. 
It  is  seldom  observed  in  early  life,  or  before  the  age  of  30.  Females 
appear  to  be  much  more  subject  to  it  than  males,  and  it  is  most  apt  to 
occur  soon  after  the  cessation  of  menstruation.  We  find  that  the  males 
who  are  attacked  by  glaucoma  frequently  suffer  from  gout  and  disorders 
of  the  digestive  organs,  and  are  often  subject  to  haemorrhoids.  There 
is  no  doubt  that  g'laucoma  may  be  hereditary,  and,  as  has  been  already 
mentioned,  the  eyes  of  the  individual  members  of  families  in  which 
this  disease  is  hereditary  often  show,  even  in  early  life,  a  peculiar 
increase  in  the  resistance  of  the  eyeball,  and  a  rigidity  and  unyielding- 
ness of  the  sclerotic  ;  and  these  symptoms  may  exist  for  many  years 
without  any  glaucomatous  outbreak.  In  fact,  the  latter  does  not 
generally  occur  until  middle  age. 

We  have  stated  that  glaucoma  may  appear  as  a  primary  or  a 
secondary  disease.  In  the  former  case,  it  may  occur  after  severe 
external  injuries,  or  without  any  apparent  external  or  internal  cause. 
It  always  attacks  one  eye  first,  and  may  remain  confined  to  this ; 
but  when  once  the  one  eye  has  become  affected  by  glaucoma,  there  is  a 
great  tendency  in  the  disease  to  invade  the  other  also.  We  must, 
therefore,  always  prepare  such  a  patient  for  the  eventuality — the  great, 
likelihood  even — of  the  other  eye  becoming  also  affected.  By  carefal 
and  judicious  treatment,  and  by  abstinence  from  excessive  fatigue  and 
exertion  of  the  eye,  much  may  be  done  to  retard  the  attack,  and  to 
break  its  force.  The  natui^e  of  the  glaucomatous  process  in  the  first 
eye  is  no  criterion  as  to  the  form  which  may  occur  in  the  other.  We 
find,  for  instance,  that  the  first  eye  may  be  suffering  from  glaucoma 
simplex,  or  chronic  inflammatory  glaucoma,  and  the  other  be  attacked 
by  the  acute  form,  or  even  by  glaucoma  fulminans.  The  time  which 
may  intervene  before  the  second  eye  becomes  affected  varies  greatly ; 
sometimes  a  few  days  only  elapse,  in  other  cases  many  months,  or  even 
years.  In  the  secondary  glaucoma,  wliich  may  supervene  upon  another 
affection  (traumatic  cataract,  irido-choroiditis,  etc.),  this  disposition 
to  extension  of  the  disease  to  the  other  eye  is  far  less  than  in  primary 
glaucoma ;  but  still  such  a  tendency  does  exist,  and  may  be  called  into 
activity  by  any  injury  to,  or  operation  upon,  the  sound  eye. 

*  For  further  inforinatior,  upon  this  interesting  and  important  subject,  I  must 
refer  the  reader  to  Von  Graefe's  and  Dr.  Ilaffmanu's  papers  on  Glaucoma,"  A.  f.  O.," 
viii,  2. 


PROGNOSIS  OF  GLAUCOMA.  479 


7.— PROGNOSIS  OF  GLAUCOMA,  ETC. 

If  the  disease  be  left  to  itself,  or  be  treated  by  inefficient  remedies, 
the  prognosis  is  most  unfavourable,  as  it  leads  sooner  or  later  to 
destruction  of  sight.  The  old  treatment,  which  consisted  in  leeching, 
cuj^ping,  mercury,  opium,  etc.,  fails,  and  is  sure  to  fail,  in  staying  the 
progress  of  the  disease.  The  acute  inflammatory  attack  may  subside 
under  their  use,  or  even  without  any  treatment  whatever  ;  the  inflam- 
matory symptoms  may  diminish,  the  refractive  media  again  become 
transparent,  the  sight  restored,  and  the  patient  and  his  medical 
attendant  may  deceive  themselves  with  the  fond  hope  that  the  dan- 
gerous disease  has  passed  away  and  is  cured.  But  this  is  not  so. 
Sooner  or  later  the  eye  again  becomes  attacked,  perhaps  by  acute 
exacerbations,  perhaps  by  insidious  chronic  inflammations,  which 
gradually  lead  to  total  and  irremediable  blindness. 

The  chief  and  most  important  indication  in  the  treatment  is  the 
diminution  of  the  abnormally  increased  intra-ocular  tension,  for  as 
long  as  this  exists  we  cannot  hope  to  arrest  the  progress  of  the  disease. 
Paracentesis  of  the  cornea  has  long  ago  been  tried  in  the  treatment  of 
glaucoma,  and  has  lately  been  again  strongly  recommended  as  a  cure 
for  this  disease ;  but  we  know  that  its  effect  is  but  transient,  that  it 
relieves  the  intra-ocular  pressure  for  a  short  time,  but  that  this  relief 
is  not  permanent,  for  increased  intra-ocular  tension  and  other  glauco- 
matous symptoms  soon  manifest  themselves  again.  Division  of  the 
ciUaiy  muscle  (as  it  has  been  termed)  has  also  been  much  vaunted  as  a 
cure  for  glaucoma.  That  it  may  temporarily  reHeve  tension  by  causing 
the  escape  of  the  aqueous,  and  perhaps  of  some  of  the  vitreous  humour, 
cannot  be  denied ;  but  tapping  the  anterior  chamber  will  do  the  same 
thing.  If  a  considerable  amount  of  vitreous  humour  flows  off,  the 
tension  may  even  be  permanently  diminished.  But  the  escape  of 
vitreous  in  glaucoma  is  a  thing  to  be  avoided  if  possible,  and  not 
to  be  desired  or  coxu'ted ;  for  we  find  that  the  loss  of  vitreous  (for 
instance,  in  the  operation  of  extraction  of  cataract)  generally  renders 
the  eye  more  prone  to  chronic  inflammatory  affections  of  the  choroid, 
accompanied  by  opacities  of  the  vitreous  humour,  etc.  At  present  no 
evidence  has  been  brought  forwrfrd  by  the  supporters  of  this  operation 
that  would  permit  of  our  placing  it  side  by  side  with  iridectomy  in  the 
treatment  of  glaucoma. 

Iiidectomy,  on  the  other  hand,  has  been  proved  to  diminish  (and  in 
the  vast  majority  of  cases  permanently),  the  abnormally  increased 
intra-ocular  tension.  The  admirable  results  of  this  operation  in  the 
treatment  of  glaucoma  have  long  admitted  of  no  doubt,  tested  and 


480  GLAUCOMA. 

endorsed  as  they  have  been  by  most  of  the  distinguished  oculists  of 
Europe. 

Some  opposers  of  the  operation  have,  apparently,  thought,  that  its 
supporters  claimed  for  it  the  power  of  restoring  sight  in  all  cases  of 
glaucoma,  whatever  their  stage  or  nature  might  be.  But  none  of  its 
advocates  have  ever  done  this ;  they  have  only  upheld  its  curative 
powers  in  those  cases  in  which  ii'reparable  changes  in  the  structures  of 
the  eye  had  not  yet  taken  place.  The  extent  of  the  benefit  which  may 
be  expected  from  iridectomy  will,  therefore,  depend  upon  the  stage  and 
form  of  the  disease,  in  wliich  it  is  had  recourse  to.  It  may  be  laid 
down  as  an  axiom,  that  the  sooner  the  operation  is  performed  when 
the  premonitory  symptoms  have  become  marked  and  frequent,  or  after 
the  outbreak  of  the  disease,  the  better ;  so  that  the  aflPection  has  not 
yet  had  time  to  produce  material  chan'ges  in  the  structures  of  the 
organ.  Let  us  now  shortly  consider  what  prognosis  may  generally  be 
given  of  the  beneficial  effects  of  iridectomy  in  the  various  stages  and 
forms  of  glaucoma. 

The  Premonitory  Stage. — As  long  as  the  premonitory  symptoms  only 
occui'  at  distant  intervals  and  the  intermissions  are  complete,  the  eye 
returning  to  its  normal  condition  during  the  intervals,  we  may  postpone 
the  operation  with  safety.  We  should,  however,  warn  the  patient 
against  any  excessive  fatigue  or  exertion  of  the  eyes,  and  their  exposui-e 
to  very  bright  light  or  rapid  changes  of  temperature ;  against  every- 
thing, in  fact,  that  may  produce  hyperaemia  and  irritation  of  the  organ, 
and  which  may  thus  hasten  the  outbreak  of  the  disease.  He  must 
also  abstain  from  excesses  of  every  kind.  But  the  system  of  lowering 
and  starving  patients  suffering  from  glaucoma  is  not  advisable,  indeed 
often  most  injurious,  more  particularly  if  they  are  elderly,  and  have 
been  very  free  livers.  Such  patients  should  be  placed  upon  an  easily 
digestible,  nourishing,  and  even  perhaps  generous  diet,  and  should 
be  permitted  a  moderate  allowance  of  stimulants,  the  quantity  being 
regulated  by  their  former  habits  and  the  condition  of  their  general 
health. 

If  the  intermissions  are  no  longer  complete,  but  there  are.  only 
remissions  of  the  symptoms ;  if  the  periodic  obscui'ations,  the  ciliary 
neui-algia,  the  iridizations,  occur  at  short  intervals  of  a  day  or  two  ;  if 
the  eccentric  vision  becomes  impaired,  or  the  field  even  contracted,  the 
vessels  congested,  and  the  eyeball  tense,  it  would  be  dangerous  to  delay 
the  operation  any  longer.  The  acute  attack  is  then  probably  imminent, 
and  we  cannot  foretell  what  its  severity  may  be,  and  whether  it  may 
not  burst  forth  in  a  very  acute  form,  even  that  of  glaucoma  fulminans, 
and  rapidly  lead  to  such  serious  lesions  of  the  structures  as  greatly  to 
imperil,  or  even  to  spoil,  the  integrity  of  the  organ,  before  operative 
aid  can  be  obtained.     But  there  is  another  reason  why  wc  should  not 


PROaNOSIS  OF  GLAUCOMA.  481 

wait  for  the  acute  outbreak  of  the  disease,  for  we  cannot  be  certain  that 
it  will  occur,  as  the  affection  raay  gradually,  and  perhaps  almost  imper- 
ceptibly, pass  over  into  chronic  glaucoma  with  excavation  of  the  optic 
nerve,  accompanied  by  such  a  deterioration  of  the  retina  and  other 
tissues  that  the  operation  may  then  prove  of  but  little  avail.  If 
iridectomy  is  performed  during  the  premonitory  stage,  when  the  symp- 
toms become  mai'ked  and  the  attacks  frequent,  but  before  any  structural 
changes  have  taken  place,  the  prognosis  is  most  favourable,  for  the 
progress  of  the  disease  is  arrested,  and  the  sight  of  the  eye  saved. 

In  acute  inflammatory  glaioccwia  the  prognosis  is  also  favourable,  if 
the  operation  is  only  performed  suflB.ciently  early.  If  the  impaii-ment 
of  vision  increases  very  rapidly,  if  the  sight  is  already  diminished  to  a 
mere  quantitative  perception  of  light,  or  if  the  visual  field  is  much 
contracted,  the  delay  of  the  operation  would  be  most  dangerous,  and  it 
should  be  performed  at  once.  We  may  generally  expect  a  nearly 
perfect  result  if  iridectomy  be  had  recourse  to  within  a  fortnight  after 
the  outbreak  of  acute  glaucoma ;  always  remembering,  however,  that 
at  least  good  quantitative  perception  of  light  must  still  be  present. 
But  we  should  never  voluntarily  wait  so  long,  as  there  is  always  a  risk 
that  during  the  delay  the  tissues  may  undergo  serious  changes.  Von 
Graefe  lays  particular  stress  upon  the  fact,  that  the  immediate  necessity 
for  the  operation  depends  less  upon  the  intensity  of  the  inflammatory 
symptoms,  the  acuteness  of  the  pain,  or  the  amount  of  increased  ten- 
sion, than  upon  the  state  of  the  vision.  If  this  be  not  greatly  impaired, 
if  the  patient  is  still  able  to  read  large  type,  the  operation  may  be  post- 
poned, if  it  be  necessary,  for  a  day  or  two.  Biit  in  the  interim,  the 
patient  must  be  closely  and  anxiously  watched,  and  if  rapid  diminution 
of  vision  occurs,  no  further  delay  must  be  permitted.  Sometimes  the 
question  may  arise,  whether  a  patient  suffering  from  an  attack  of  acute 
glaucoma  may  be  permitted,  if  necessary,  to  undertake  a  journey  in 
order  to  have  the  operation  performed,  or  whether  he  may  be  safely 
allowed  to  wait  until  the  inflammation  has  subsided,  and  the  eye  has 
again  become  "  quiet."  Here  I  must  strongly  urge  the  necessity  of  not 
delaying,  for  if  the  journey  be  postponed  until  the  inflammation  is 
allayed,  the  eye  may  be  found  to  be  irretrievably  lost.  The  journey 
would  have  proved  far  less  dangerous  than  the  delay.  But  even  if  the 
most  favourable  event  should  occur,  if  the  inflammation  should  subside, 
and  the  eye  apparently  regain  its  former  condition,  we  know  but  too 
well  that  the  disease  is  not  cured,  that  it  will  sooner  or  later  recur, 
either  in  the  acute  form  or  as  clironic  glaucoma.  In  the  latter  case, 
the  progress  may  be  so  insidious  that  serious  and  irreparable  changes  in 
the  optic  nerve,  the  retina,  and  the  coats  of  the  vessels  may  have 
occurred,  before  the  patient's  attention  is  attracted  to  the  state  of  his 
eye. 

2  I 


482  GLAUCOMA. 

In  glaucoma  fulminans  the  operation  mtist  he  performed  as  soon  as  pos- 
sible. The  structures  undergo  such  great  and  rapid  changes,  that  the 
effect  of  the  operation  may  not  be  perfect  even  when  it  is  performed 
within  three  days  after  the  outbreak  of  the  disease,  as  was  shown  in  a 
case  of  Von  Grraefe's. 

In  those  cases  of  acute  glaucoma  in  which  the  pain  is  very  intense, 
and  there  is  much  inclination  to  vomit,  but  the  impairment  of  vision  is 
only  moderate.  Yon  Graefe  thinks  it  may  be  better  to  wait  a  day  or  two 
before  performing  iridectomy.  Here  he  employs  the  subcutaneous 
injection  of  morphia,  gr.  \  to  i,  in  the  region  of  the  temple,  in  order  to 
procure  a  good  night's  rest,  and  to  quiet  the  nervous  system  before 
operating.  But  if  we  give  chloroform  the  operation  need  not,  I  think, 
be  postponed  on  this  account.  In  fact,  iridectomy  proves  the  best  anti- 
phlogistic, and  its  beneficial  effects  in  acute  glaucoma  are  most  marked 
and  brilliant  if  it  be  performed  sufficiently  early.  The  relief  of  the 
often  agonising  pain  is  generally  immediate ;  patients  soon  fall  into 
a  tranquil  and  refreshing  sleep,  after  having  perhaps  passed  several 
sleepless,  miserable  nights ;  the  inflammatory  symptoms  rapidly  subside  ; 
the  sight  is  greatly  improved,  partly  from  the  diminution  in  the  intra- 
ocular pressure,  and  partly  frora  the  escape  of  the  turbid  aqueous 
humour.  This  improvement  rapidly  increases  during  the  first  fort- 
night, and  is  generally  due  to  the  absorption  of  the  retinal  ecchymoses 
which  occm-red  during  the  operation.  The  improvement  of  sight 
reaches  its  maximum  extent  about  two  months  after  the  operation.  If 
the  latter  has  been  performed  sufficiently  early,  vision  is  generally  per- 
fectly restored,  the  patient  being  able  to  read  the  very  finest  print 
(with,  of  course,  the  proper  glasses,  if  he  is  presbyopic),  and  this  im- 
provement is,  in  the  vast  majority  of  cases,  permanent.  Such  a  result 
may  even  be  expected  up  to  within  a  fortnight  after  the  outbreak,  if,  at 
the  time  of  the  operation,  there  was  still  good  perception  of  light  and 
no  considerable  contraction  of  the  field. 

In  the  later  stages  of  acute  glaucoma  the  results  of  the  operation 
vary.  In  such  cases,  the  prognosis  will  depend  upon  the  extent  to 
which  the  degenerative  alterations  in  the  tissues  have  already  advanced. 
The  prognosis  may  be  favourable  if  the  visual  field  is  only  moderately 
contracted,  more  particularly  if  the  contraction  is  not  sHt-shaped  but 
concentric,  the  fixation  central,  and  vision  not  very  greatly  impaired, 
especially  if  the  impairment  depends  upon  cloudiness  of  the  refractive 
media  and  increased  intra-ocular  tension.  The  operation  will  generally 
not  only  restore  an  excellent  and  useful  amount  of  vision,  but  this 
improvement  will  mostly  be  permanent.  It  is  different,  however,  if  the 
field  is  greatly  contracted,  especially  if  it  be  slit-shaped,  if  the  fixation 
is  eccentric,  vision  much  impaired,  and  the  latter  due,  not  to  opacity  of 
the  refractive  media,  but  to  an  already  considerable  excavation  of  the 


PROGNOSIS  OF  GLAUCOMA.  483 

optic  nerve  and  deterioration  of  the  retina.  Here  the  prognosis  must 
be  guarded,  for  although  the  operation  may  do  much  even  in  such  cases, 
the  good  results  may  sometimes  not  be  permanent,  but  the  sight  be 
gradually  lost  again,  either  through  recurrence  of  inflammatory 
attacks,  or  througli  progressive  excavation  and  atrophy  of  the  optic 
nerve. 

I  have  already  stated  that  iridectomy  sometimes  proves  of  but 
little  avail  in  the  hajmorrhagic  form  of  glaucoma,  on  account  of  the 
extensive  intra-ocular  bleeding  which  ensues  upon  the  operation.  It 
may  afford  temporary  rehef,  but  relapses  are  but  too  frequent ;  and 
although  these  may  be  alleviated  by  repeating  the  operation,  yet  the 
eye  cannot  generally  be  finally  rescued,  although  in  some  cases  a  certain 
amount  of  sight  may  be  perhaps  preserved. 

In  chronic  inflammatory  glaucoma  the  prognosis  must  also  be  guarded. 
The  progress  of  the  disease  is  but  too  often  so  insidious,  that  the  patients 
do  not  apply  for  medical  aid  until  very  considerable  changes  have  taken 
place  in  the  tissues,  more  particularly  the  optic  nerve  and  retina. 
Iridectomy  will,  however,  generally  arrest  the  disease,  and  preserve  the 
existing  amount  of  vision,  or  even  improve  it.  This  is  particularly  the 
case  if  the  fixation  is  still  central,  the  sight  not  too  much  impaired,  the 
optic  nerve  not  deeply  excavated,  and  the  field  of  vision  not  slit-shaped, 
but  contracted  laterally  or  concentrically.  In  such  cases,  the  progress 
of  the  disease  and  of  the  structural  changes  is  generally  stayed,  and 
the  existing  amount  of  vision  permanently  preserved.  The  beneficial 
effects  of  the  operation  are,  however,  far  more  slowly  developed  than 
in  acute  glaucoma.  Months  elapse  before  the  improvement  has  reached 
its  maximum  degree,  or  before  we  can  be  certain  that  the  effect  will  be 
permanent.  But  even  when  the  field  is  greatly  contracted  and  the 
fixation  very  eccentric,  we  may  yet  occasionally  be  able  permanently  to 
preserve  a  certain  amount  of  sight,  enough  perhaps  to  enable  the  patient 
to  find  his  way  about.  And  even  this  little  must  be  looked  upon  as  a 
great  boon  in  comparison  with  total  blindness.  But  in  such  cases,  the 
effect  of  the  operation  is  sometimes  only  temporary,  the  tension  of  the 
eye  again  increases,  the  vision  slowly  but  steadily  deteriorates,  leading  at 
last  to  complete  loss  of  sight.  This  is  far  more  frequently  due  to  pro- 
gressive atrophy  of  the  optic  nerve,  than  to  a  recurrence  of  the 
glaucomatous  symptoms.  Should  a  recurrence  of  the  glaucomatous 
inflammatory  symptoms,  with  increased  tension,  take  place,  the  ope- 
ration may  be  repeated  with  benefit.  This  is  particularly  the  case  when 
the  original  iridectomy  has  not  been  sufficiently  large,  or  the  iris  has 
not  been  removed  quite  up  to  its  ciliary  insertion. 

Von  Graefe  has  called  attention  to  the  fact,  that  a  whitish  discolora- 
tion of  the  optic  nerve  (which  is  generally  a  symptom  of  progressive 
atrophy)  sometimes  occurs  in  glaucoma,  and  even  increases  in  intensity 

2  I  2 


484  GLA.UCOMA. 

for  some  niontlis  after  the  operation  (particularly  in  cases  of  some 
standing),  without  endangering  the  sight.  The  discoloration  progresses 
up  to  a  certain  point  and  then  remains  stationary.  It  is  only  dangerous, 
when  this  increasing  whiteness  is  accompanied  by  a  simultaneous 
deterioration  of  vision. 

Even  in  those  cases  of  glaucoma  which  are  not  accompanied  by 
manifest  inflammatory  symptoms  (glaucoma  simplex),  we  find  that 
iridectomy  proves  of  service.  Here,  as  in  chronic  glaucoma,  the 
misfortune  often  is,  that  the  patient  does  not  apply  until  the  disease 
has  f;xr  progressed.  If  only  one  eye  is  aflTected,  this  may  be  nearly 
lost  before  the  patient  even  discovers  that  anything  is  the  matter 
with  it,  and  then  on  examination  we  find  that  the  disease  has  nearly, 
if  not  completely,  run  its  course,  that  there  are  such  serious  changes  in 
the  structures  that  the  operation  can  prove  but  of  little  if  any  avail. 
It  is  otherwise  if  the  second  eye  becomes  afiected  with  the  same  form 
of  disease ;  for  then  the  patients  speedily  seek  medical  aid,  and  will 
consent  to  a  timely  operation,  even  although  their  sight  raay  still  be 
good.  In  order  to  arrest  the  disease  permanently,  the  operation  must 
be  performed  early,  before  irreparable  changes  in  the  tissties  have  been 
produced.  Graefe  particularly  urges  that  the  operation  should  be  per- 
formed in  time,  and  should  not  be  delayed  until  considerable  impairment 
of  vision  or  inflammatory  symptoms  manifest  themselves.  Here  also 
the  beneficial  effects  of  the  iridectomy  show  themselves  slowly  and 
gradually.  If  the  atrophy  of  the  optic  nerve  has  not  proceeded  too 
far,  a  steady,  though  slow,  improvement  will  take  place.  He  has  seen 
cases  in  which,  during  a  period  varying  from  half  a  year  to  tliree  years, 
the  field  of  vision  and  the  sight  had  gradually  but  persistently  dete- 
riorated, and  where,  after  iridectomy  (during  a  period  of  observation 
extending  from  one  to  three  years),  either  a  complete  arrest,  or  even  a 
considerable  improvement,  occurred.  Such  improvement  also  occurred 
in  two  cases  in  which,  together  with  a  perfectly  typical  excavation,  all 
appreciable  increase  of  tension  was  absent.  He  considers  that  the  im- 
provement is  the  more  likely,  if  the  impairment  of  sight  depends  not 
only  upon  the  condition  of  the  optic  nerve,  but  is  also  due  to  a  still 
evident  impediment  in  the  conducting  power  of  the  retina. 

In  glaucoma  ahsiilutam,  in  which  all  sight,  even  the  quantitative 
perception  of  light,  is  lost,  iridectomy  is  never  indicated  except  to 
diminish  the  inflammatory  symptoms  or  severe  pain.  For  these  pur- 
poses it  is  to  be  performed,  care  being  taken  to  impress  upon  the  patient 
and  his  friends  that  the  object  of  the  operation  is  to  ameliorate  his 
sufferings,  and  not  to  restore  the  sight.  The  iridectomy  should  always 
be  of  a  large  size.  In  cases  of  glaucomatous  degeneration  it  may  also  be 
necessary  to  employ  it  for  the  same  purpose.  Should  it  prove  vmable 
to   arrest    tlic    inflammatory  exacerbations,  should    it    be    followed  by 


PROGNOSIS  OP  GLAUCOMA.  485 

extensive  haemorrhages,  or  slioiihl  these  occur  spoutaiieously,  and  all 
sight  is  lost,  the  question  may  arise  whether  it  would  not  be  better  to 
remove  the  eye  altogether ;  for  there  may  be  a  fear  of  the  other  eye 
sympathizing. 

I  have  endeavoured  to  point  out  as  plainly  and  simply  as  possible, 
the  facts  which  should  guide  us  in  forming  a  prognosis  of  the  beneficial 
effects  to  be  expected  from  iridectomy.  Nor  have  I  made  any  state- 
ment the  accuracy  of  which  I  have  not  myself  frequently  tested.  This 
part  of  the  subject  demands  the  most  earnest  attention,  as  too  slight  a 
regard  for  the  different  facts  which  should  influence  our  prognosis  of 
the  effect  of  iridectomy  in  glaucoma,  lias  been  one  of  the  chief  reasons 
why  this  operation  has  proved  unsuccessful  in  the  hands  of  some 
practitioners. 

Eow  iridectomy  diminishes  the  abnormally  increased  intra-ocular 
pressure  in  glaucoma  has  not  yet  been  decided.  That  it  does  in  the 
vast  majority  of  cases  permanently  relieve  the  tension  is,  however,  an  un- 
doubted and  incontrovertible  fact.  Various  theories  have  been  advanced 
in  order  to  explain  the  modus  ojjera/ndi.  Amiongst  other  hypotheses,  some 
have  thought  that  the  tension  was  diminished  by  the  excision  of  a  con- 
siderable portion  of  the  secreting  (iris)  surface;  others,  that  the 
removal  of  the  iris  quite  up  to  its  ciliary  insertion,  and  the  consequent 
exposure  of  the  zonula  Zinnii,  facilitates  the  interchange  of  fluid  between 
the  vitreous  and  aqueous  humours,  and  thus  diminishes  the  difference  in 
the  degree  of  tension  between  these  humours.  We  must  admit,  how- 
ever, that  this  problem  has  not  at  present  been  satisfactorily  solved. 
Now  some  opponents  of  the  operation  apparently  reject  it,  because  the 
solution  of  the  modus  operandi  has  not  yet  been  found.  They  would 
rather  deprive  their  hapless  patients  of  the  benefits  of  iridectomy,  which 
would,  in  all  probabiHty,  either  restore  or  preserve  vision  ;  they  Avould 
rather  permit  them  to  lose  their  sight,  than  perform  an  operation  the 
effect  of  which  in  diminishing  tension,  though  fully  proved,  they  cannot 
at  present  satisfactorily  explain. 

Some  writers  have  stated  that  the  operation  of  iridectomy,  as  it  is 
to  be  pel-formed  in  glaucoma,  is  just  the  same  as  the  old  operation  for 
artificial  pupil.  Nothing  could  be  more  erroneous.  The  principle  of 
the  two  operations  is  perfectly  different.  In  the  old  operation,  an 
opening  was  made  in  the  cornea,  and  a  small  portion  of  iris,  in  pro- 
portion to  the  desired  size  of  the  pupil,  excised.  In  the  modern  opera- 
tion of  iridectomy  for  glaucoma,  the  chief  point  is  to  make  the  incision 
in  the  sclerotic,  or  at  the  sclero-corneal  junction,  and  of  a  sufficient 
extent  to  permit  the  removal  of  a  large  segment  of  the  iris  (about 
one-fifth)  quite  up  to  its  ciliary  attachment.  The  more  intense  the 
symptoms,  the  more  considerable  the  increase  in  the  intra-ocular 
tension,   the  larger  should  the  iridectomy  be.     Many  of  the  negative, 


48(5  GLAUCOMA. 

or  only  partially  successful,  results  wliich  have  followed  the  employ- 
ment of  iridectomy  in  glaucoma,  were  undoubtedly  often  due  to  some 
fault  in  the  performance  of  the  operation.  Either  too  small  a  portion 
of  the  iris  was  excised,  or  it  was  not  removed  quite  up  to  its  ciliary 
attachment.  We  sometimes  find  that  if  only  a  small  portion  is 
removed,  and  this  not  up  to  the  ciliary  insertion,  the  symptoms  do  not 
completely  yield,  and  more  or  less  increase  of  tension  remains.  If,  in 
such  a  case,  a  second  and  larger  iindectomy  is  made,  and  the  iris 
removed  quite  up  to  its  ciliary  attachment,  the  beneficial  effects  at 
once  become  apparent,  the  tension  diminishes,  the  inflammation  sub- 
sides, and  the  vision  improves.  The  iridectomy  should  be  made 
upwards,  for  the  upper  lid  generally  covers  the  greater  portion  of 
the  artificial  pupil,  and  thus  not  only  hides  the  slight  deformity,  but 
also  cuts  ofi"  much  of  the  irregularly  refracted  light.  But  this  opera- 
tion is  somewhat  more  difficult  than  that  in  the  horizontal  direction, 
and  consequently  the  beginner  will  do  well,  at  first  to  perform  the 
operation  outwards  or  inwards.  For  a  full  description  of  the  mode  of 
performing  iridectomy,  I  must  refer  the  reader  to  p.  172. 

In  those  cases  of  fully-developed  glaucoma,  in  which  iridectomy  has 
only  been  able  to  preserve  a  certain  amount  of  sight,  considerable 
benefit  is  often  experienced  from  the  application  of  the  artificial  leech 
to  the  temple  some  months  afterwards. 

I  must  in  conclusion  call  attention  to  certain  disadvantages  which 
may  ensue  upon  iridectomy,  but  these  are  slight  indeed  when  com- 
pared with  the  inestimable  boon  which  the  operation  affords  in  this 
disease. 

In  the  first  stages  of  acute  glaucoma,  the  operation  upon  one  eye 
may  accelerate  the  outbreak  of  the  disease  in  the  other,  even  although 
the  latter  may  have  been  quite  sound.  The  patient  should  therefore 
be  warned  of  such  an  eventuality,  but  it  should  not  cause  us  to  post- 
pone or  shrink  from  the  operation,  as  we  know  how  dangerous  any  delay 
is  in  acute  glaucoma. 

Again,  some  siTrgeons  have  thought  that  iiidectomy  may  cause  a 
rapid  development  of  cataract.  But  this  is  not  so,  for  wherever  shortly 
after  iridectomy  a  cataract  is  formed  in  a  previously  healthy  lens,  this 
nmst  be  considered  as  due  to  a  solution  of  continuity  of  the  capsule 
(generally  by  the  point  of  the  knife).  As  the  anterior  chamber  is  very 
shallow  in  glaucoma,  and  the  pupil  often  widely  dilated,  the  extract  of 
Calabar  bean  should  be  applied  shortly  before  the  operation,  in  order 
that  the  pupil  may  become  greatly  contracted,  and  the  lens  be  covered. 
Or,  Von  Graefe's  narrow  cataract  knife  may  be  used  instead  of  the 
lance-shapcd  iridectomy  knife,  for  with  it  we  can  skirt  the  margin  of 
the  anterior  chamber,  and  yet  obtain  a  very  large  and  peripheral 
incision.     We  cannot,  however,  regulate   the  escape  of  the  aqueous 


PROGNOSIS  OF  GLAUCOMA.  487 

humour  so  well  with  this  instrument  as  with  the  iridectomy  knife ; 
and  a  sudden,  forcible  discharge  of  the  aqueous,  may  not  only  give  rise 
to  severe  intra-ocular  hsBmorrhage,  but  also  to  a  spontaneous  rupture 
of  the  capsule  and  a  subsequent  catai'act. 

Although  the  section  as  a  rule  heals  perfectly,  without  leaving  any 
or  but  the  slightest  trace  behind,  we  occasionally  meet  with  instances 
in  which  this  is  not  the  case,  the  lips  of  the  incision  being  separated  by 
a  web  of  cicatricial  fibres,  which  show  a  tendency  to  bulge  out,  owing 
to  the  intra-ocular  pressure,  in  the  form  of  small  vesicular  or  bead-like 
elevations.  Indeed  the  cicatrix  may  even  give  way  repeatedly,  and  the 
aqueous  humour  escape  under  the  conjunctiva.  Von  Graefe  terms  this 
peculiar  mode  of  union  of  the  incision  "  ci/stoid  cicatrix."  It  occurs  chiefly 
in  those  cases  in  which  there  has  been  considerable  and  marked  increase 
of  tension  for  some  time  before  the  operation,  also  where  glaucomatous 
excavation  has  supervened  upon  sclerectasia  posterior;  and  finally, 
according  to  Bowman,  if  the  tension  remains  somewhat  in  excess  after  the 
iridectomy.  Von  Graefe,  on  the  contrary,  has  found  the  tension  of  eyes 
with  the  cystoid  cicatrix  rather  less  than  normal. 

If  a  tendency  to  this  form  of  cicatrization  shows  itself,  a  compres- 
sive bandage  should  be  at  once  applied,  and  continued  for  several  days 
or  even  longer,  being  afterwards,  if  necessary,  periodically  repeated.  If 
the  bulge  is  considerable,  it  should  be  pricked  with  the  point  of  the 
narrow  knife,  or  a  broad  needle,  so  as  to  allow  the  aqueous  humour  to 
escape,  and  the  collapsed  membrane  is  then  to  be  snipped  ofi"  with  a  pair 
of  scissors.  Mr.  Bowman  advises  that  it  should  be  repeatedly  pricked 
with  a  broad  needle.  It  is  not  safe  to  touch  it  with  caustic,  as  this 
might  set  up  serious  irritation. 


Chapter  XIII. 

THE    ANOMALIES    OF    REFRACTION    AND 
ACCOMMODATION   OF   THE   EYE. 


1.— THE  REFRACTION  AND  ACCOMMODATION  OF  THE 

EYE. 

The  affections  of  the  refraction  and  accommodation  of  the  eye  are  daily 
assuming  more  importance,  and  are  engaging  more  and  more  the  atten- 
tion of  some  of  onr  most  able  and  scientific  ophthalmologists.  For  it  is 
now  known  that  certain  forms  of  asthenopia  and  amblyopia  which  had 
in  former  times  set  all  remedies  at  defiance,  are  not  due,  as  was  gene- 
rally supposed,  to  serious  lesions  of  the  inner  tunics  of  the  eyeball,  but 
are  in  reality  dependent  iipon  some  anomaly  of  the  refraction  of  the 
eye,  or  a  peculiar  asym.metry  of  the  organ  (astigmatism).  Since  the 
discovery  of  these  important  facts  a  considerable  group  of  cases  has 
been  found  to  be  amenable  to  treatment ;  cases  which  had  formerly 
sorely  puzzled  the  oculist,  and  were  by  him  but  too  often  deemed 
incurable. 

The  greater  the  strides  which  have  been  made  in  the  investigation 
of  the  affections  of  the  refraction  and  accommodation,  the  more  evi- 
dent has  it  become  how  essentially  necessary  it  is  that  they  should  be 
thoroughly  and  carefully  studied,  and  scientifically  treated.  I  would 
therefore  impress  upon  the  student  the  fact  that,  after  he  has  made 
himself  conversant  with  the  theoretical  portion  of  the  subject,  it  is 
only  by  a  practical  and  oft-repeated  examination  of  a  considerable 
niimber  of  cases,  that  he  can  acquire  the  requisite  facility  in  the  exami- 
nation of  the  state  of  refraction  and  of  the  range  of  accommodation,  or  in 
the  choice  of  spectacles.  To  those  who  may  consider  these  subjects  as 
somewhat  abstruse  and  difficult,  I  would  reply,  that  the  difficulties  lie 
only  on  the  surface,  and  that  a  little  perseverance  and  practice  will 
soon  enable  them  to  unravel  the  knotty  points. 


THE   REFRACTION   AND   ACCOMMODxVTION   OP   THE   EYE.       489 

Befcn'o  we  enter  upon  the  subject  of  tlic  refraction  and  accommo- 
dation of  the  eye,  we  must  very  briefly  consider  the  properties  of  optical 
lenses.  For  spectacles,  the  spherical  biconvex  and  biconcave  lenses  are 
almost  solely  used,  and  I  shall  therefore  confine  myself  to  tlieir  descrip- 
tion. In  the  article  upon  astigmatism,  the  properties  of  cylindrical  lenses 
will  be  explained. 

The  biconvex  lens  is  formed  by  the  apposition  of  a  segment  of  two 
spheres,  the  radii  of  curvature  of  the  two  surfaces  being  equal.  Such 
lenses  are  often  also  termed  converging  lenses,  as  they  possess  the  power 
of  deflecting  a  ray  of  light,  passing  through  them,  towards  the  axis. 
The  line  drawn  through  the  centre  of  the  lens  (Fig  56,  c)  is  teiTned 
the  axis,  and  any  ray  passing  through  it  (axial  ray)  is  not  deflected. 

(1.)  If  parallel  rays  (from  a  luminous  object  at  an  infinite  distance)* 
fall  upon  a  biconvex  lens,  they  are  united  at  a  certain,  point  behind  the 
lens,  and  this  point  is  called  the  principal  focus  (or  simply  the  focus)  of 
the  lens.  The  distance  of  this  point  from  the  optic  centre  of  the  lens 
(which  equals  the  radius  of  curvature  of  the  lens),  is  termed  the  fijcal 
length  of  the  lens.  Thus,  if  in  Fig.  56  Hs  a  biconvex  lens  of  6  inches 
focus,  parallel  rays  (r  ?•)  will  be  united  at  /,  6  inches  behind  the  lens. 
(2.)  If  the  object  be  now  brought  closer  to  the  lens  to  r',  so  that  the 
rays  emanating  from  it  assume  a  divergent  direction,  they  will  be 
brought  to  a  focus  at  /',  lying  at  some  distance  behind  the  principal 
focus  (/)  of  the  lens.     (3.)   If  the  object  is  situated  at  twice  the  focal 


length  of  the  lens,  the  rays  from  it  will  be  united  at  a  point  placed 
twice  the  focal  length  behind  the  lens,   and  hence  the  distance  of  the 

*  As  the  term  infinite  distance  will  necessarily  be  of  freqnent  occurrence  in 
these  pages,  it  will  be  well  to  explain  its  siguKlcation  at  the  outset.  We  consider 
an  object  to  be  at  a  finite  distance,  as  long  as  rays  emanating  from  it  faU  in  a  diver- 
gent direction  upon  the  eye.  Of  course  rays,  even  from  a  very  distant  object,  do  in 
reality  diverge,  but  this  divergence  (which  naturally  decreases  in  extent  the  furtlier 
the  object  is  removed),  is  ah-eady  so  slight  wlien  the  object  is  placed  at  a  distance 
of  18  or  20  feet,  that  the  rays  from  it  impinge,  to  all  intents  and  purposes,  parallel 
upon  the  eye.  We  therefore  consider  rays  coming  from  an  object  situated  further 
than  18  feet  as  parallel,  and  as  emanating  from  an  object  at  an  infinite  distance. 
Rays  coming  from  a  nearer  object  are  divergent  in  proportion  to  its  proximity,  and 
are  considered  as  conning  from  a.  finite  distance. 


490  ANOMALIES  OF   REFRACTION   AND   ACCOMMODATION. 

object  and  of  its  focus  from  the  lens  will  be  the  same.  (4.)  If  the 
object  be  placed  at  the  principal  anterioi'  focal  point,  i.e.,  6"  in  front  of 
the  lens  (Fig.  57  /'),  the  rays  will  emerge  from  the  lens  parallel  to  its 
axis  r  r.  (5.)  If  the  object  is  placed  inside  the  principal  focus  (Fig. 
57,  r')  the  rays  from  it  will  be  so  divergent  that  the  lens  will  not  be 

Fig.  57. 


able  to  render  them  even  parallel,  and  they  will  therefore  emerge  from 
it  still  somewhat  divergent.  This  divergence  will  of  course  be  less 
than  before  they  entered  the  lens,  and  if  the  rays  (r"  r")  are  prolonged 
back  to  the  point  at  which  they  would  cut  each  other,  this  point  would 
lie  at/",  being  situated  further  from  the  lens  than  the  object  r .  The 
focus  (/")  of  these  rays  is  therefore  imaginary,  and  situated  on  the 
same  side  of  the  lens  as  the  object.  (6.)  If  convergent  rays  (rendered 
so  by  some  other  lens)  fall  upon  the  lens,  they  will  be  brought  to  a 
focus  on  the  other  side  of  the  lens,  at  a  point  lying  nearer  than  the 
principal  focus. 

It  has  been  shown  above,  that  the  further  the  object,  from  which 
divergent  rays  fall  upon  the  lens,  is  removed  from  the  latter,  the  nearer 
will  the  focus  of  such  rays  approach  the  principal  focus  of  the  lens ; 
whereas  the  closer  the  object  is  brought  (provided  that  it  remain  further 
off  than  the  principal  focus)  the  more  will  its  focus  recede  from  the 
lens.  On  account  of  this  dependence  of  these  two  points  (the  position 
of  the  object  and  its  focus)  upon  each  other,  they  are  termed  conjugate 
foci.  Moreover,  if  the  position  of  the  object  and  its  focus  were  changed, 
so  that  the  object  were  placed  at/'  (Fig.  56),  the  rays  from  it  would  be 
brought  to  a  focus  on  the  other  side  of  the  lens  at  r' ,  the  point  where 
the  object  was  situated  before ;  hence/'  and  r'  are  conjugate  foci.  Again, 
if  the  object  be  placed  at  /,  its  rays  will  emerge  parallel  fi^om  the 
lens. 

Hitherto  we  have  only  spoken  of  the  refraction  of  rays  which  are 
parallel  to  the  axis  of  the  lens,  and  whose  focus  is  situated  upon  the 
axis.  We  must  now  consider  the  focus  of  rays,  the  axes  of  which  pass 
through  the  centre  of  the  lens,  but  which  are  inclined  to  the  axis. 
Such  are  termed  secondary  axes.  The  inclination  must  not,  however, 
be  too  considerable,  otherwise  the  rays  will  not  be  brought  to  an  exact 


THE  REFRACTION  AND  ACCOMMODATION  OF  THE  EYE.   491 

focus,  on  account  of  the  great  spherical  aberration  which  occurs.  Thus 
in  Fig.  58,  let  A  B  be  the  principal  axis  of  a  lens,  r  a  luminous  point 
situated  on  this  axis,  and /the  focus  at  which  the  rays  from  rare  united. 
Now  let  ?•'  be  another  luminous  point  situated  at  the  same  distance  from 
the  lens  as  r,  but  not  on  the  principal  axis,  but  at  a  certain  inclination 

Fig.  58. 


towards  it.  The  secondary  axis  A'  B'  will  pass  straight  through  the 
centre  (c)  of  the  lens  without  undergoing  any  deflection,  and  the  rays 
from  r'  will  be  brought  to  a  focus  at  f ,  which  will  be  situated  on  the 
secondary  axis  A  B',  at  the  same  distance  behind  the  lens  as  /.  Just  as 
/is  the  conjugate  focus  of  r,  will/  be  the  conjugate  focus  of  r'. 

We  shall  now  be  able  to  understand  the  manner  in  which  a  biconvex 
lens  forms  an  image  of  any  luminous  object  situated  in  front  of  it.  Let 
ABC  (Fig.  59)  be  an  object  situated  in  front  of  the  lens.     The  rays 

Fig.  59. 


emanating  from  A  will  be  focused  at  a  point  a  situated  on  the  secondary- 
axis,  drawn  from  A  through  the  centre  c  of  the  lens  ;  a  is  consequently 
the  image  of  -4 ;  in  the  same  manner  c  is  the  image  of  C,  and  the  rays 
from  J5,  situated  on  the  principal  axis  of  the  lens,  are  united  at  h,  likewise 
placed  on  this  axis,  hence  h  is  the  image  of  B.  A  reverse  and  smaller 
image  of  the  object  A  B  G  \^  therefore  formed  behind  the  lens  at  a  h  c. 
The  rays  which  pass  through,  the  centre  c  of  the  lens  are  not  deflected ; 
and  ah  c  are  the  conjugate  foci  oi  A  B  G.  The  distance  G  B  and  c  &  is 
also  conjugate,  for  if  the  object  be  placed  at  a  b  c,  its  inverted  and 
enlarged  image  would  be  formed  at  A  B  G. 

Now  the  size  of  the  image  formed  by  the  lens  will  depend  upon  the 
distance  at  which  the  object  is  situated.    (1.)  If  the  latter  is  placed  at  an 


492  ANOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

infinite  distance,  the  smallest  inverted  image  will  be  formed  behind  the 
lens  at  its  principal  focus.  (2.)  If  the  object  be  approximated  so  as  to 
lie  at  double  the  focal  length  of  the  lens,  its  inverted  image  will  be 
situated  at  double  the  focal  length  behind  the  lens,  and  be  the  same 
size  as  the  object.  (3.)  If  the  object  be  brought  still  closer,  but  yet 
further  than  the  anterior  focus,  the  inverted  image  will  move  further 
away  from  the  lens  and  be  larger  than  the  object.  (4.)  If  the  latter 
be  placed  at  the  anterior  focus  no  real  image  will  be  formed,  for  the  rays 
will  issue  from  the  lens  in  a  parallel  direction.  (5.)  If  the  object  is 
placed  inside  the  focal  length,  the  rays  will  still  issue  in  a  divergent 
direction  from  the  lens,  and  the  latter  will  act  as  a  magnifying  glass, 
the  image  will  not  be  inverted  and  situated  behind  the  lens,  but  will  be 
erect,  magnified,  and  situated  in  front  of  the  lens.,  i.e.,  on  the  same  side 
as  the  object.     Fig.  60  will  explain  this.     If  yl  i?  be  an  object  situated 


closer  to  the  lens  I  than  its  anterior  focus  F,  the  rays  from  A  will  still 
divei^ge  after  their  passage  through  the  lens,  and  in  such  a  direction  as 
if  they  came  from  a,  and  the  rays  from  B  will  diverge  as  if  they  came 
from  h.  If  the  eye  E  is  placed  on  the  other  side  of  the  lens,  it  will  see 
instead  of  the  object  A  B,  its  magnified,  erect  image,  a  b. 

This  magnifying  power  of  the  lens  will  be  greater  according  to  the 
shortness  of  its  focal  length,  thus  a  4-inch  lens  magnifies  more  than  a 
5-inch,  and  the  latter  more  than  a  6-inch  lens.  In  order  therefore  to 
give  the  correct  magnifying  power,  and  to  demonstrate  at  once  that  a 
6-inch  lens  magnifies  less  than  a  5-inch,  we  designate  the  magnifying 
power  of  a  lens  by  fractions,  the  numerators  of  which  are  one,  the 
denominators,  the  focal  length  of  the  lens.  Thus  one-fourth  is  stronger 
than  one-fifth,  the  latter  fraction  being  less  than  the  former.  More- 
over, this  way  of  expressing  the  strength  of  the  lens  is  also  correct,  as 
indicating  its  power  of  refraction,  for  a  lens  of  one-fifth  will  deflect 
rays  of  light  impinging  upon  it  more  than  a  lens  of  one-tenth. 

If  parallel  rays  fall  upon  a  biconvex  lens,  they  are  united  into  a 
real  focus  behind  the  lens.     It  is  difierent,  however,  Avith  a  biconcave 


THE   REFRACTION   AND   ACCOMMODATION   OF   THE   EYE.        493 

or  "  diverging  "  lens,  for  this  does  not  unite  parallel  rays,  but  renders 
them  divergent.  Thus  (1),  if  parallel  rays  (Fig-  61,  r  r)  fall  u[)()n  a 
concave  lens  they  will  be  rendered  divei^gent,  assuming  a  direction  as  if 

Fig.  61. 


they  had  proceeded  from/,  in  which  the  prolongation  backwards  of  the 
divergent  rays  r  r  would  cut  one  another,  hence  this  point  is  called  the 
negative  virtual  focus  of  the  lens,  and  is  an  imaginary  one,  being  situated 
upon  the  same  side  as  the  object.  The  distance  of  this  point  for  parallel 
rays  from  the  lens,  gives  the  focal  distance  of  the  lens.  Thus  a  con- 
cave lens  of  10  inches  focus,  renders  parallel  rays  so  divergent,  as  if 
they  came  from  a  distance  of  10  inches  in  front  of  the  lens.  (2.)  If  the 
object  is  brought  closer  to  the  lens,  so  that  the  rays  emanating  from  it 
will  diverge,  they  will  be  rendered  still  more  divergent  by  the  concave 
lens,  and  their  focus  will  lie  closer  to  the  lens  than  its  principal 
imaginary  focus. 

"We  have  now  to  consider  the  manner  in  which  the  eye  receives 
upon  the  retina  a  clear  and  shai"ply- defined  image  of  an  object  placed 
in  front  of  it. 

We  may  regard  the  eye  as  a  camera-obscura,  upon  the  screen 
(retina)  of  which  is  formed  a  diminished  and  inverted  image  of  the 
object.  The  impression  of  the  object  will  be  formed  upon  the  bacillar 
layer  (rods  and  cones)  of  the  retina,  be  conveyed  thence  through  the 
fibres  of  the  optic  nerve  to  the  brain,  be  there  received,  and  then  pro- 
jected back  again  in  an  inverted  direction  outwards  to  the  object. 
The  most  sensitive  portion  of  the  retina  being  situated  at  the  yellow 
spot,  this  point  is  always  directed  towards  any  object  at  which  we  are 
looking.  The  sensibility  of  the  retina,  which  diminishes  rapidly  from 
the  yellow  spot  towards  the  periphery,  may  be  excited  by  the  undula- 
tions of  rays  of  light,  or  by  mechanical  means.  The  former  excitation 
occurs  when  rays,  emanating  from  a  luminous  object,  impinge  upon 
the  retina ;  the  latter,  when  the  eyeball  is  slightly  pressed  by  the  point 
of  the  finger,  which  will  produce  the  appearance  of  luminous  rings 
(phosphenes),  situated  apparently  in  a  direction  opposite  to  that  of  the 
pressui-e.  Thus,  if  the  outer  portion  of  the  sclerotic  be  pressed  upon, 
the  luminous  ring  will  appear  at  the  nasal  side,  and  vice  versa. 


494    ANOMALIES  OF  REFRACTION  AND  ACCOMMODATION. 

The  refractive  power  of  the  normal,  emmetropic  eye  is  such,  that 
rays  which  emanate  from  a  distant  object,  and  impinge  in  a  parallel 
direction  tipon  the  cornea  are  brought  to  an  exact  focus  upon  the 
retina,  and  the  eye  receives  a  distinct  image  of  such  an  object.  The 
dioptric  system  of  the  eye  which  causes  this  refraction  of  the  rays  of 
light,  consists  of  certain  media,  which,  taken  conjointly,  act  as  a  biconvex 
lens.  These  refractive  media  are  the  cornea,  aqueous  humour,  crystal- 
line lens,  and  vitreous  humour.  On  account  of  the  slight  thickness  of 
the  cornea,  the  parallelism  of  its  two  surfaces,  and  the  fact  that  the 
refracting  power  of  the  cornea  and  aqueous  humour  are  nearly  equal, 
we  may  assume  that  the  two  form  only  one  refracting  surface.  The 
index  of  the  refraction  of  the  vitreous  humour  is  almost  the  same  as 
that  of  the  aqueous.  But  the  refraction  of  the  cornea  and  of  the  aqueous 
and  vitreous  humours  would  not  suffice  to  bring  parallel  rays  to  a 
focus  upon  the  retina  in  an  emmetropic  eye,  for  the  focus  would  lie 
considerably  behind  it,  and  the  lens  is  required  to  render  the  rays 
sufficiently  convergent.  The  axis  of  the  dioptric  system  is  called  the 
optic  axis,  the  anterior  extremity  of  which  corresponds  to  the  centre 
or  apex  of  the  cornea,  and  the  posterior  extremity  to  a  point  situated 
between  the  yellow  spot,  and  the  entrance  of  the  optic  nerve.  By  the 
term  visual  line  is  meant  the  line  of  du'ection  drawn  straight  from  the 
object  (through  the  nodal  point)  to  its  image  formed  at  the  yellow 
spot.  It  was  formerly  supposed  that  the  optic  axis  and  visual  line 
were  identical,  but  this  is  not  so,  for  according  to  Helmholtz,*  the 
visual  line  outside  the  eye  lies  somewhat  above  and  to  the  inner  side 
of  the  optic  axis,  and  its  posterior  extremity  on  the  retina  consequently 
lies  a  little  to  the  outer  and  lower  side  of  the  axis.  This  fact  will  be 
found  of  practical  importance  with  regard  to  the  question  of  real  and 
apparent  strabismus. 

If  we  now  apply  to  the  eye,  the  principles  laid  down  above  as  to  the 
properties  of  biconvex  lenses,  we  can  easily  understand  the  raode  in 
which  the  reverse  image  of  an  object  is  formed  upon  the  retina.  Thus, 
\?  A  B  G  (Fig.  62)  be  an  object  placed  at  the  proper  distance  from  the 

Fig.  62. 


*  Ilelmholtz's  Pliysiologische  Ojitik.,  p.  70. 


THE   REFRACTION   AND   ACCOMMODATION   OF   THE   EYE.       495 

eye,  a  distinct  inverted  image  of  it  Avill  be  formed  upon  the  retina  at 
ah  c.  Let  J?  J  be  the  axial  ray  passing  through  the  nodal  point  to  the 
retina.  Through,  this  nodal  point  draw  a  straight  line  from  A  to  a. 
This  line  A  a  will  be  a  secondary  optic  axis,  and  all  the  rays  emanating 
from  A  ^vill  be  focused  upon  the  retina  at  a.  The  straight  line  G  c, 
passing  through  the  nodal  point,  will  be  another  secondary  optic  axis, 
and  all  the  rays  from  C  will  be  united  upon  the  retina  at  c.  Hence 
ah  c  will  be  the  inverted  diminished  image  of  A  B  C. 

Now  the  question,  whether  or  not  the  rays  from  the  object  will  be 
brought  to  a  focus  upon  the  retina,  and  the  latter  thus  receive  a  clearly- 
defined  image,  mil  depend  upon  the  situation  of  the  object,  and  the 
distance  for  which  the  dioptric  system  of  the  eye  is  accommodated. 
The  same  principles  as  were  laid  down  with  respect  to  biconvex 
lenses  apply  to  this  case.  Thus,  if  an  eye  is  adjusted  for  parallel 
rays,  these  will  be  brought  to  a  focus  upon  the  retina.  If  the  object  is 
now  brought  nearer  to  the  eye,  so  that  its  rays  become  divergent,  they 
will  no  longer  be  united  upon  the  retina,  but  behind  it.  The  eye  will 
consequently  not  receive  a  clearly-defined  image,  but  the  latter  will  be 
blurred  and  indistinct,  on  account  of  the  "circles  of  difiusion  "  formed 
upon  the  retina.  As  the  focus  of  the  rays  lies  behind  the  retina,  each 
luminous  point  from  the  object  is  no  longer  presented  by  a  point  upon 
the  retina,  but  by  a  circle  (the  section  of  each  conical  pencil  of  rays), 
and  as  these  circles  overlap  each  other,  the  image  is  rendered  indis- 
tinct. These  are  called  circles  of  difi'usion,  and  take  the  form  of  the 
pupil,  consequently  their  size  diminishes  with  that  of  the  pupil,  and 
vice  versa. 

For  the  more  exact  calculation  of  the  passage  of  rays  of  light 
through  the  eye.  Listing  constructed  a  diagrammatic  eye  (Fig.  63) 
having  six  cardinal  points,  corresponding  to  those  of  optical  lenses  and 
situated  on  the  optic  axis.  1.  The  focus  F  (Fig.  63)  situated  upon 
the  retina,  in  which  rays  falling  parallel  upon  the  cornea  would  be 

Fig.  63. 


united.      2.    The  anterior  focus  F\  at  which  rays  coming  from  the 
retina,  and  whose  course  is  parallel  in  the  vitreous  humour,  would  be 


496  ANOxMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

brought  to  a  focus.  3.  The  two  "principal  points  "  B"  i?' which  lie 
on  the  optic  axis  in  the  anterior  chamber  close  behind  the  cornea  (in 
Fig.  63  these  two  points  lie  somewhat  too  far  from  the  cornea). 
4.  The  two  "nodal  points"  KK',  in  which  the  Hnes  of  direction  cut  each 
other,  and  which  near  the  posterior  surface  of  the  lens. 

On  account  of  the  extremely  small  distance  (less  than  ;|^  of  a 
millimetre)  between  the  two  principal  points  and  the  two  nodal  points, 
this  diagrammatic  eye  may  be  simplified,  and  these  four  cardinal  points 
be  reduced  to  two,  viz.,  a  principal  point  situated  in  the  anterior 
chamber,  and  a  nodal  point,  situated  somewhat  in  front  of  the  posterior 
surface  of  the  lens.  The  two  focal  points  remain  the  same.  For  the 
method  of  calculating  the  course  of  the  rays  of  light  according  to  the 
cardinal  points,  I  must  refer  the  reader  to  Helmholtz's  Physiologische 
Optik,  and  Donders'  work  on  the  Anomalies  of  Refraction  and  Accom- 
m.odation. 

A  glance  at  Fig.  63  will  also  explain  the  relative  positions  of  the 
optic  axis  (F  F')  and  of  the  visual  line  (VV).  The  latter  is  an 
imaginary  line  drawn  from  the  yellow  spot  to  the  object  point.  They 
were  formerly  supposed  to  be  identical,  but  Helmholtz  has  found  that 
this  is  not  the  case,  but  that  in  front  of  the  eye  the  visual  line  lies 
inwards  and  generally  somewhat  upwards  of  the  optic  axis,  its  posterior 
(retinal)  extremity  consequently  lying  to  the  outer  side  of  the  optic 
axis  and  sKghtly  below  it.  Thus  in  Fig.  63  (which  represents  a  hori- 
zontal section  of  the  diagrammatic  eye,  the  upper  side  of  the  figure 
being  the  temporal,  the  lower  the  nasal  side)  V  V  is  the  visual  line  and 
F  F'  the  optic  axis.  At  the  cornea,  the  former  lies  to  the  inner  side, 
at  the  retina,  to  the  outer  side  of  the  optic  axis.  At  the  nodal  point 
K  they  cross  each  other. 

In  the  normal  or  emmetropic  eye  the  visual  line  impinges  upon  the 
cornea  slightly  to  the  inner  side  of  the  optic  axis,  forming  with  it  an 
angle  of  about  5°.  But  Donders  has  shown  that  in  the  hypermetropic 
eye  it  lies  still  more  to  the  inner  side,  so  as  to  form  an  angle  of  8°  or  9°, 
whereas  in  myopia  the  visual  line  may  correspond  to  the  optic  axis,  or 
even  lie  to  the  outer  side  of  it.  These  difierences  in  the  relation 
between  the  optic  axis  and  visual  line  often  give  rise  to  an  apparent 
strabismus. 

The  Visual  Anyle. — The  apparent  size  of  an  object  depends  upon  the 
size  of  its  retinal  image.  If,  for  instance,  the  eye  is  adjusted  for  the 
objects  B  (Fig.  64)  and  the  lines  of  direction,  A  A'  and  B  B',  are  drawn 
through  the  nodal  point  I;  the  angle  Ah  B  will  be  the  visual  angle 
under  which  the  object  is  seen,  and  this  angle  will  equal  the  angle  A'  Jc  B'. 
The  visual  angle  stands  in  direct  relation  to  the  size  of  the  object,  foi- 
the  larger  the  latter  is,  the  greater  will  be  the  visual  angle,  and  con- 
sequently the  image,  and  vice  versa.     Moreover,  the  visual  angle  will 


THE   REFRACTION   AND   ACCOMMODATION   OF    THE   EYE.       4i)7 

also  increase    in  size  according  to   the  proximity  of  tlie  object,    and 
diminish  as  the  latter  is  farther  removed  from  the  eye.      If,  however, 

Fig.  61. 


the  size  of  the  object  increases  in  due  proportion  vpith  its  distance,  it 
will  be  seen  under  the  same  visual  angle.  Thus  A  B  (Fig.  64)  and  a  b 
are  seen  under  the  same  visual  angle,  although  the  former  is  con- 
siderably further  from  the  eye  than  a  h.  From  this  it  will  be  easily 
understood,  that  the  mere  fact  of  a  patient  being  able  to  read  the  smallest 
print  does  not  exclude  a  certain  degree  of  amblyopia.  In  deciding  upon 
this  point,  we  must  always  take  into  consideration  the  distance  at  which 
he  can  read  it,  and  the  state  of  refraction  and  accommodation. 

The  smallest  visual  angle  under  which  an  object  can  be  distinctly 
seen  by  the  eye  is  one  of  5°.  Hence  this  has  been  taken  as  the  standard 
for  determining  the  acuteness  of  vision,  and  the  test  types  of  Snellen 
and  Gii-aud  Teulon  have  been  devised  upon  this  principle,  as  has  been 
already  stated  (p.  4),  each  type  being  seen  under  an  angle  of  5°  at 
the  distance  in  feet  corresponding  to  its  number.  Thus  'No.  1  is  seen 
at  an  angle  of  5  minutes  at  1  foot,  No.  2  at  2  feet,  etc. 


We  have  now  to  turn  our  attention  to  the  nearer  consideration  of 
the  subject  of  refraction  and  accommodation. 

By  the  term  "accommodation"  is  meant  the  power  w^iich  every 
normal  eye  possesses  of  adjusting  itself  almost  imperceptibly  and  un- 
consciously for  different  distances.  At  one  moment,  looking  at  some- 
tiling  but  a  few  inches  from  the  eye,  at  the  next,  regarding  some  far 
distant  object,  or  taking  in  at  a  glance  the  vast  expanse  of  miles  of 
scenery. 

In  a  normal  eye  the  whole  apparatus  of  accommodation  is  so  beauti- 
fully balanced,  and  its  functions  are  performed  with  such  ease  and  accu- 
racy, that,  although  in  reality  a  voluntary  act,  its  duties  are  from  early 
childhood  fulfilled  intuitively,  unconsciously.  No  wonder,  then,  that 
this  power  of  adjustment  of  the  eye  to  different  distances  has  been  a 
favourite  study  with  some  of  the  most  eminent  physiologists  and 
natui'al  philosophei's. 

2   K 


498  ANOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

That  sucli  a  power  is  essentially  necessary  will  become  at  once 
apparent  by  a  consideration  of  tbe  following  fact,  and  a  glance  at 
Fig.  65. 

It  lias  been  already  stated  that  the  emmetropic  eye  in  a  state  of 
rest  is  adjusted  for  parallel  rays  a  a,  so  that  these  are  brought  to  a 
focus  upon  the  retina  h,  without  any  effort  of  the  accommodation.  But 
if  the  object  is  now  brought  to  c  (12"*  from  the  eye)  the  rays  will  be 
very  divergent,  and  will  be  focused  behind  the  retina  at  cl,  unless  the 

Fin;.  65. 


eye  can  increase  its  power  of  refraction  sufficiently  to  unite  them  upon 
the  retina.  If  not,  cii'cles  of  diffusion  will  be  formed  upon  the  latter, 
and  the  object  consequently  appear  blurred  and  indistinct.  If  the  ac- 
commodation of  the  eye  is  paralysed,  rays  from  the  object  c,  12"  in 
front  of  the  eye,  would  be  brought  to  a  focus  upon  the  retina  by  the  aid 
of  a  bi- convex  lens  of  12  inches  focus,  which  would  render  the  rays 
parallel  and  thus  enable  the  eye  to  focus  them  upon  the  retina. 

It  is  very  necessary  carefully  to  distinguish  between  the  meaning 
of  the  terms  refraction  and  accommodation,  as  they  signify  two  perfectly 
different  things.  By  refraction  is  understood,  the  passive  power  which 
every  eye  possesses,  when  in  a  state  of  rest, — i.e.,  adjusted  for  its  far 
point — of  bringing  certain  rays  to  a  focus  upon  the  retina  without  any 
active  effort  or  participation  of  the  muscular  apparatus  of  accomjnoda- 
tion.  This  power  of  refraction  is  due  to  the  form  of  the  eye  and  its 
different  refracting  media. 

We  have  just  seen  (Fig.  65)  that  the  state  of  refraction  of  the  normal 
eye  is  such  that,  when  it  is  in  a  state  of  rest,  parallel  rays  are  brought 
to  a  focus  upon  the  retina  without  any  effort  of  the  accommodation.  Its 
furthest  point  of  distinct  vision  lies  at  an  infinite  distance.  Bonders 
terms  this  condition  emmetropia.  He  says,t  "  the  refraction  of  the 
media  of  the  eye  at  rest  can  be  called  normal  in  reference  to  the  situa- 

*  I  may  rcmmd  the  reader  of  the  signification  of  the  following  expressions  :  A, 
means  range  of  accommodation;  r,  far  point;  p,  near  point;  oo  (=0),  infinite 
distance;  ',  foot;   ",  inch;  '",  line. 

f  Bonders  "  On  the  Anomalies  of  Accommodation  and  Refraction  of  the 
Eye,"  p.  81.     New  Sydenham  Society,  1864. 


THE  REFRACTION  AND  ACCOMMODATION  OF  THE  EYE. 


499 


tion  of  the  ret  inn,  only  when  parallel  incident  rays  unite  on  the  layer 
of  rods  and  bulbs.  Then,  in  fact,  the  limit  lies  precisely  at  the  measure  ; 
then  there  exists  emmetropia  (from  efifKj-rpo'i,  modum  tenens,  and  wyy, 
oculus).     Such  an  eye  we  term  emmetropic. 

"  This  name  expresses  perfectly  what  we  mean.  The  eye  cannot  be 
called  a  normal  eye,  for  it  may  very  easily  be  abnormal  or  morbid,  and 
nevertheless  it  may  be  emmetropic.  Neither  is  the  expression  normally 
const nccted  eye  quite  correct,  for  the  structure  of  an  emmetropic  eye 
may,  in  many  respects,  be  abnormal,  and  emmetropia  may  exist  with 
difference  of  structiu-e.  Hence  the  word  emmetropia  appears  alone  to 
express  with  precision  and  accuracy  the  condition  alluded  to." 

The  state  of  refraction  may  deviate  in  two  ways  from  the  emmetropic 
condition. 

1.  The  principal  focus  of  the  eye,  when  adjusted  for  its  far  point,  hes 
in  front  of  the  retina  (Fig.  60),  so  that  parallel  rays  are  not  brought  to 
a  focus  upon  the  latter,  but  in  front  of  it  /,  and  circles  of  diffusion,  h  h, 
will  be  formed,  only  sufficiently  divergent  rays  being  united  upon  the 
retina.     This  condition  is  termed  myopia ;  also  brachymetropia  (/S/ja^vs 

Fig.  66. 


brevis,  judrpov,  modus,  w^^,  oculus,  the  limit  lies  within  the  measure), 
and  depends  upon  the  eyeball  being  too  long,  or  the  state  of  refraction 
too  high.  A  suitable  concave  lens  will  be  required  to  unite  the  parallel 
rays  upon  the  retina  (Fig.  66). 

2.  The  principal  focus  may  lie  behind  the  retina,  so  that  when  the  eye 
is  in  a  state  of  rest,  parallel  rays  are  brought  to  a  focus  behind  the  retina 
(?•,  Fig.  67)  at  the  point/.     Circles  of  diffusion  h  b  are  formed,  and  the 


Fig.  67. 


2  K  2 


500  ANOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

object  looks  indistinct.  This  condition  is  termed  liypermetropla  (i^re/j, 
super,  fierpov,  modus,  wi/^,  ocnlas,  the  hmit  lies  beyond  the  measure). 
To  remedy  this  indistinctness  of  the  image,  the  eye  undergoes  a  change 
in  its  accommodation,  so  as  to  increase  its  power  of  refraction,  and 
render  the  parallel  rays  sufficiently  convergent  to  be  united  upon  the 
retina.  The  same  effect  may  be  produced  by  placing  a  suitable  convex 
lens  before  the  eye. 

In  order  to  express  that  the  eye  is  not  emmetropic,  Bonders  pro- 
poses the  term  ametropia  (from  a/nerpov,  extra  modum,  and  ai'Y-^,  oculus)  ; 
and  he  observes  that  brachymetropia  and  hypermetropia  are  both, 
therefore,  referrible  to  it.  Formerly  presbyopia  and  myopia  were  sup- 
posed to  be  opposite  conditions.  This  is,  however,  erroneous.  In 
myopia  there  is  an  abnormal  position  of  the  far  point,  whereas  in  pres- 
byopia the  position  of  the  far  point  is  normal,  but  that  of  the  near 
point  is  changed,  being  removed  further  from  the  eye.  Indeed  presby- 
opia and  myopia  may  co-exist.  Presbyopia  is  not,  therefore,  an  anomaly 
of  refraction,  but  a  diminution  in  the  range  of  accommodation. 

It  has  long  been  a  keenly  debated  question  in  what  the  changes  of 
accommodation  of  the  eye  consist,  and  various  opinions  have  been 
advanced.  Some  have  thought  that  the  cornea  undergoes  some  alte- 
ration during  accommodation  for  near  objects,  so  that  its  power  of 
refraction  is  increased,  and  the  eye  enabled  to  adjust  itself  for  read- 
ing, writing,  &c. ;  but  apart  from  other  reasons  against  this  theory, 
Helmholtz  has  shown,  with  his  ophthalmometer,  that  there  is  no  alte- 
ration in  the  curvature  of  the  cornea  during  accommodation.  Others 
have  supposed  that  the  muscles  of  the  eyeball  play  an  important  part 
in  bringing  about,  in  conjunction  with  the  ciliary  muscle,  the  adjust- 
ment for  near  objects.  But  that  this  is  not  the  case  has  been  incontro- 
vertibly  proved  by  a  case  of  Von  Graefe's,  in  which  all  the  recti  and 
obliqui  muscles  of  both  eyes  were  paralysed,  so  that  the  eyeballs  were 
completely  immoveable,  and  yet  the  power  of  accommodation  was 
perfect. 

It  has  at  length,  however,  been  definitely  settled,  chiefly  by  the 
experiments  of  Cramer  and  Helmholtz  (conducted  independently  of 
each  other),  that  the  necessary  change  in  the  refraction  of  the  eye 
during  accommodation  is  due  to  an  alteration  in  the  form  of  the  crystal- 
line lens.  Helmholtz  found,  by  means  of  his  ophthalmometer,  that  the 
lens  did  not  change  its  position  during  accommodation  for  near  objects, 
but  that  this  was  brought  about  by  a  change  in  the  curvature  of  the 
anterior  and  posterior  surfaces  of  the  lens,  which  become  more  convex 
(the  lens  itself  thicker  from  before  backwards),  so  that  the  lens 
acquires  a  higher  power  of  refraction,  and  consequently  a  less  focal 
distance,  by  which  means  rays  from  even  very  near  objects  are  brought 
to  a  focus  upon  the  retina.     He  found,  with  the  ophthalmometer,  that 


THE   REFRACTION   AND   ACCOMMODATION   OF   THE   EYE.       50] 

tlie  eye  undergoes  the  following  changes  during  accommodation  for 
near  objects  : — 

1.  The  pupil  diminishes  in  size.  2.  The  pupillary  edge  of  the  iris 
moves  forwards.  3.  The  peripheral  portion  of  iris  moves  backwards. 
4.  The  anterior  surface  of  the  lens  becomes  more  convex  (arched),  and 
its  vertex  moves  forwards.  5.  The  posterior  surface  of  the  lens  also 
becomes  slightly  more  arched,  but  does  not  perceptibly  change  its 
position.     The  lens,  therefore,  becomes  thicker  in  the  centre.* 

As  the  volume  of  the  lens  must  remain  the  same,  he  thinks  that  we 
may,  moreover,  assume  that  the  transverse  diameter  of  the  lens  be- 
comes diminished.  He  finds,  from  calculation,  that  these  changes  in 
the  lens  are  quite  sufficient  for  all  accommodative  purposes. f 

Fig.  68  illustrates  the  changes  which  the  eye  undergoes  during  ac- 
commodation.    The  anterior  portion  of  the  eye  is   dix-ided  into  two 

Fig.  68. 


equal  parts.  The  one  half,  F,  shows  the  position  of  the  parts  when  the 
eye  is  adjusted  for  distance,  the  other,  N,  when  it  is  accommodated  for 
near  objects.     When  the  eye  is  in  a  state  of  rest,  the  iris  forms  a  curve 

*  Otto  Becker  has  found  that  in  albinotic  eyes  the  space  between  the  ciliary 
processes  and  the  edge  of  the  lens,  becomes  increased  in  size  during  accommodation 
for  near  objects.  He  thinks  it  probable  that  the  volume  of  the  ciliary  processes 
varies  in  the  different  conditions  of  the  accommodation,  and  supposes  that  this  is 
due  to  the  diiference  in  tlie  blood  supply  to  the  iris,  which  he  thinks  varies  \Wtli  the 
dilatation  and  contraction  of  the  pupil. 

+  It  was  found,  with  the  ophthalmometer,  that  the  position  of  the  reflection 
images  of  a  candle,  produced  by  the  cornea  and  the  anterior  and  posterior  surfaces 
of  the  lens,  underwent  a  change  during  accommodation  for  near  objects.  Whilst  the 
reflex  image  from  the  cornea  remained  unchanged,  that  from  the  anterior  siu"face 
of  the  lens  approached  the  corneal  image  and  diminished  in  size ;  the  image  from 
the  posterior  surface  of  the  lens  also  diminished  very  slightly  in  size,  but  under- 
went no  appreciable  change  of  position. 


502  ANOMALIES   OF  REFRACTION   AND   ACCOMMODATION. 

(ft)  in  the  vicinity  of  Sdalemm's  canal  (s)  ;  but  when  accommodated 
for  near  objects,  the  fibres  of  the  iris  snfFer  contraction,  the  periphery  of 
the  iris  becomes  straightened  (Z>),  and  the  anterior  chamber  lengthened, 
so  that  its  diminution  in  depth  is  compensated  for  by  the  advance  of 
the  anterior  surface  of  the  lens. 

The  question  now  arises  in  what  manner  is  this  change  in  the  form 
of  the  lens  produced  ?  There  can  be  no  doubt  now  that  it  is  entirely 
due  to  the  action  of  the  ciliary  muscle.  .  Cramer,  Donders,  Helmholtz, 
Miiller,  as  well  as  many  other  observers,  considered  that  whilst  the 
ciliary  muscle  played  the  most  important  part  in  the  mechanism  of  the 
accommodation,  it  was  materially  assisted  by  the  iris.  Indeed  it  was 
impossible  to  determine  with  accui^acy,  even  after  the  most  careful 
dissections  and  most  elaborate  investigations,  the  relative  amount  of 
importance  of  the  iris  and  ciliary  muscle.  This  question  has  now, 
however,  been  definitely  set  at  rest  by  a  case  which  occurred  in  Yon 
Graefe's  clinique,  in  which,  together  with  a  total  absence  of  the  iris  (the 
latter  was  removed  after  an  accident)  the  power  of  accommodation 
remained  perfect.  Moreover,  on  the  application  of  a  strong  solution  of 
atropine  it  became  completely  paralysed. 


2.— NEGATIVE  ACCOMMODATION. 

Some  ophthalmologists  of  eminence,  more  especially  Von  Graefe  and 
Weber,  have  thought  that  when  the  emmetropic  eye  is  in  a  state  of 
rest,  it  is  not  quite  adjusted  for  its  furthest  point  of  distinct  vision,  but 
can  become  so  by  a  slight  alteration  in  its  accommodation,  which  may 
be  called  the  negative  accommodation,  in  contradistinction  to  the  positive 
which  enables  it  to  adjust  itself  for  near  objects.  Von  Graefe  has 
thought  that,  by  the  aid  chiefly  of  the  external  muscles  of  the  eyeball 
which  exert  a  slight  pressure  upon  the  eye,  and  thus  somewhat  flatten 
the  cornea,  the  refraction  of  the  eye  is  slightly  diminished,  and  the  far 
point  removed  still  further  from  the  eye,  than  when  the  eye  is  in  a  state 
of  absolute  rest.  Henke,*  however,  thinks  that  both  the  positive  and 
the  negative  accommodation  are  produced  by  the  action  of  the  ciliary 
muscle.  The  former  being  due  to  the  action  of  its  circular  fibres,  the 
latter  to  that  of  its  radial  fibres. 

The  chief  argument  against  the  theory  that  the  eye  accommodates 
itself  actively  for  distant  objects  is  furnished  by  the  action  of  a  strong- 
solution  of  atropine,  which  completely  paralyses  the  power  of  accommo- 
dation, but  does  not  interfere  with  the  distant  vision  of  an  emmetropic 
eye,  and  does  not  change  the  position  of  its  far  point. 

*  "A.  f.  O.,"  vi,  2,  53. 


THE   RANGE   OF   ACCOMMODATION.  503 


3.— THE  RANGE  OF  ACCOMMODATION. 

When  the  eye  has  assumed  its  highest  state  of  refi-action,  it  is 
accommodated  for  its  nearest  point  of  distinct  vision ;  when  its  state 
of  refraction  is,  on  the  other  hand,  relaxed  to  the  utmost,  it  is  adjusted 
for  its  furthest  point. 

But  as  the  power  of  the  ciliary  muscle  is  limited,  the  accommodation 
for  near  objects  must  also  be  limited,  and  the  near  point  cannot  be 
approximated  closer  than  a  certain  distance  to  the  eye.  In  the  youthful 
emmetropic  eye  it  lies  at  about  3^  to  4  inches  from  the  eye,  but  recedes 
further  and  further  with  advancing  age.  The  furthest  point  of  distinct 
vision  in  the  emmetropic  eye  lies  at  an  infinite  distance.  The  furthest 
point  of  distinct  vision  is  expressed  by  the  letter  /•  (punctum  remotissi- 
mum),  the  nearest  point  by  p  (punctum  proximum).  The  distance 
between  these  two  is  called  the  range  of  accommodation.  The  extent 
of  this  range  varies,  of  course,  according  to  the  sti'ength  and  efficiency 
of  the  cihary  muscle,  the  elasticity  of  the  lens,  and  the  age  of  the 
patient.  The  distance  of  p  from  the  eye  (measured  from  the  nodal 
point)  is  expressed  by  P,  the  distance  of  r  from  the  eye  by  R.  Now 
the  range  of  accommodation  can  be  easily  found  if  we  assume  it  to 
equal  the  focal  length  of  a  lens  which  would  give  to  the  rays  emanating 
from  an  object  placed  at  the  nearest  point  (jj)  a  direction  as  if  they 
came  from  the  furthest  point  (/•).  Let  us  suppose  that  the  eye  is  em- 
metropic and  accommodated  for  an  object  placed  at  its  far  point 
(parallel  rays),  if  the  object  is  now  moved  up  to  5"  from  the  eye,  and 
the  latter  does  not  exert  its  power  of  accommodation,  the  rays  from  the 
object  will  be  brought  to  a  focus  behind  the  retina.  In  order  to  unite 
them  upon  the  latter,  a  bi-convex  lens  must  be  placed  before  the  eye, 
which  shall  render  the  rays  coming  from  the  object  (placed  at  5") 
parallel,  i.e.,  give  them  the  same  direction  as  they  had  when  the  object 
was  situated  at  an  infinite  distance.  A  5-inch  lens  would  be  required 
for  this  purpose,  for  the  rays  from  an  object  situated  at  its  anterior 
focal  length  would  issue  parallel  from  the  lens.  If  we  now  suppose  this 
auxiliary  lens  placed  within  the  eye,  it  represents  the  accommodation  of 
the  eye,  and  its  power  the  range  of  accommodation,  the  latter  would, 

therefore,  in  this  case  =  -.      The  range  of  accommodation  —  may  be 
5  A 

found  by  the  formula  —  =  —  —  —. 
^  APR 

Let  us  illustrate  this  by  a  few  examples  : — 

1.  If  the  furthest  point  lies  at  an  infinite  distance,  R  =   oo,  the 

nearest   point   at  6"  P   =   6",  the   range  of  accommodation  will  be 


504  ANOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

-,  for  _  —  =  -.     The  rano-e  of  accommodation  is  here  repi'esented 

by  an  auxihary  lens  of  6  inches  focus. 

2.  If  in  a  myopic  eye,  the  far  point  lies  at  8"  and  the  near  point 

at   4"    from   the    eye,    the    range    of  accommodation   will   be   -  for 

o 

1  _1  ^  1 

4       8       8' 

3.  If  a  presbyopic  eye  has  its  far  point  at  an  infinite  distance,  and 

its    near   point   at  10",  the  ransre  of  accommodation    will  be  —  for 

J_  _    1    ^  J_ 

10       ^       10' 

The  following  is  also  a  very  good  method  for  testing  the  range  of 
accommodation,  and  for  quickly  discovering  whether  the  eye  is  emme- 
tropic, myopic,  or  hypermetropic  : — 

A  convex  lens  of  6"  or  10"  focus  is  placed  before  the  eye.*  With 
this  lens  the  patient  then  reads  No.  1  of  Snellen,  and  his  far  and  near 
point  are  noted.  The  far  (/•')  and  near  point  (jj')  thus  found,  stand  in 
such  relation  to  his  real  far  (r)  and  near  point  (j)),  that  the  rays  coming 
from  ■)•'  are  refracted  by  the  lens  as  if  they  came  from  r,  those  from  j?' 
being  also  refracted  as  if  they  emanated  from  p.  With  convex  6,  r'  (in 
the  normal  eye)  lies  at  6"  from  the  eye,  for  rays  from  an  object  at  6" 
distance  falling  on  this  lens,  would  be  rendered  parallel  by  it,  and  would, 
consequently,  impinge  upon  the  eye  as  if  they  came  from  an  infinite 
distance  (the  normal  far  point).  The  near  point  (p)  would  lie  at  about 
2f".     This  varies,  however,  with  the  age  of  the  patient. 

The    range    of  accommodation   is,    therefore,   easily  found  by  the 

formula    —  =  ^_  —  __.    The   lens   and    its    distance    from    the    eye 
APR  ^ 

(about  ^")  are  omitted  in  the  calculation. 

If  (with  convex  6)  the  far  point  (r')  lies  at  G",  the  near  point  (2^') 

at3",   i  =  L-i  =  l. 
A       3       6        6 

Let  us  illustrate  this  proceeding  by  the  following  examples : — 
I.  Myopic  eye.    We  find  that  with  convex  6  r'  =  B",  p'  =  3".     The 
eye  is  consequently  myopic,  for  it  is  not  adjusted  for  the  normal  far 
point  (6'),  but  for  a  nearer  one,  the  rays  from  which  impinge  in  a  diver- 
gent direction  upon  the  eye  : — -    =-  —  -  =  7;^- 

A       o       o         /■g' 

*  Tlie  lens  must  be  strong,  in  order  that  the  patient  may  really  command  his 
far  point,  and  that  the  latter  may  be  approximated  so  much  that  the  minimum  of 
the  angle  of  distinction  no  longer  exerts  any  influence,  and  amblyopia  is  therefore 
excluded. 


THE   RANGE   OF   ACCOMMODATION.  505 

Now,  wliat  glasses  will  this  patient  require  for  infinite  distance  ? 
By  means  of  our  strong  convex  lens  we  have  changed  this  eye  into  a 
very  myopic  one,  in  fact,  into  a  myopia  of  y,  for  we  should  have  to 
place  a  concave  glass  of  5"  focus  before  convex  6,  in  order  to  enable  it 
to  see  at  a  distance ;  for  this  concave  glass  would  render  parallel  rays 
so  divergent  as  if  they  came  fi'om  5"  distance.  In  order  to  find  the 
proper  concave  glass  for  distance,  we  deduct  concave  6  from  convex  6. 

Hence  the  proper  concave  glass  will  be  No.  30  for  -  —  -  =  —  —  . 

6       5  30 

II.  Hiipermetroplc  eije.     With  convex  6,  r   =:  8,  p   =  3".     The  eye 

is,  therefore,  hypermetropic,  for  its  far  point  lies  beyond  the  normal  far 

point  (6"). 

Its  ranffe  of  accommodation  =:   —  for  -    =  _  —  _  z=  _   . 

^  4A        A       3       8       4| 

Above  we  have  only  spoken  of  the  absolute  range  of  accommodation 
which  exists  when  each  eye  is  tried  separately.  Bonders*  has,  how- 
ever, pointed  out  that  we  must  distinguish  two  other  kinds  of  ranges, 
viz.,  the  hinocular  and  the  relative.  The  binocular  comprises  the  accom- 
modation from  the  farthest  point  Ti  to  the  nearest  point  jh,  when  both 

eyes  are  tried  tosrether.     The  formula  is  —  =  —  — 

Ao        P^        R,. 

Although  a  certain  connection  exists  between  the  accommodation 
and  the  convergence  of  the  visual  lines,  yet  this  connection  is  not  abso- 
IvTte  and  definite,  for  we  find  that  the  position  of  the  visual  lines  may 
be  changed,  yet  the  accommodation  remain  the  same ;  for  if  a  prism  of 
moderate  strength  be  placed  with  its  base  outwards  before  one  eye,  the 
convergence  of  the  visual  lines  will  be  greatly  increased  to  overcome 
the  diplopia,  and  yet  the  object  can  be  distinctly  seen  at  the  same 
distance  with  both  eyes.  Again,  the  accommodation  may  be  altered, 
and  yet  the  state  of  convergence  remain  the  same,  for  if  we  place 
weak  concave  or  convex  lenses  before  the  eyes,  an  object  can  still  be 
distinctly  seen  at  a  definite  distance.  This  proves  that  the  accommo- 
dation may  be  modified  without  any  change  of  the  convergence  of  the 
visual  lines.  These  experiraents  show  that  there  exists  a  certain  inde- 
pendence between  the  convergence  and  the  accommodation,  and  the 
range  of  accommodation  over  which  we  have  control  at  a  given 
convergence  of  the  visual  lines  is  termed  the  relative  range,  and  is  found 

by  the  formula  —  ^  —  —  — -.    It  consists,  moreover,  of  two  parts,  the 
Ai        Pi        Ri 

positive  and  the  negative.  The  positive  being  the  part  which  is  dis- 
posable for  a  distance  closer  than  the  point  of  convergence,  whereas 
the  negative  is  the  portion  which  is  required  to  see   an  object  lying 

*  Op.  cit.,  110.  Full  explanations,  with  explanatory  diagrams  of  this  subject, 
will  be  found  in  Donders'  work. 


506     ANOMALIES  OF  REFRACTION  AND  ACCOMMODATION. 

beyond  the  point  of  convergence  of  the  visual  h'nes.  Now  the  relation  be- 
tween these  two  parts  of  the  relative  range  of  accommodation  is  of  much 
practical  importance,  for  it  is  found  that,  in  order  that  the  eyes  may 
be  employed  comfortably  for  some  length  of  time  at  near  objects 
(reading,  etc.),  it  is  absolutely  necessary  that  the  positive  part  of  the 
accommodation  shotdd  bear  a  certain  proportion  to  the  negative  (it 
should  at  the  very  least  be  equal  to  -^) . 

The  best  objects  for  testing  the  range  of  accommodation  are 
Snellen's  test  types  or  Von  Graefe's  wire  optometer.  But  as  the  latter 
requires  some  exactitude  and  intelligence  on  the  part  of  the  patient,  I 
find  it  more  practical,  especially  with  hospital  patients,  to  use  the  test 
types.  If  whilst  they  are  reading  No.  1  we  move  the  type  a  few  times 
alternately  nearer  to  and  further  from  the  eye,  the  nearest  and  furthest 
point  of  distinct  vision  can  be  readily  ascertained.  Von  Graefe's  opto- 
meter consists  of  a  small  square  steel  frame,  across  which  a  number  of 
delicate,  parallel,  vertical  wires  are  stretched.  This  frame  may  be 
attached  to  a  brass  rod  (graduated  in  inches  and  feet)  upon  which  it  is 
moveable  ;  or  it  may  be  fastened  to  a  graduated  tape.  One  end  of  the 
rod,  or  the  bobbin  of  the  tape  is  placed  against  the  forehead  of  the 
patient,  and  the  frame  moved  to  the  nearest  point  at  which  the  indi- 
vidual wires  still  look  clearly  and  sharply  defined ;  the  distance  of  this 
point  from  the  eye  is  read  off  from  the  graduated  scale,  and  put  down 
as  the  near  point  {})).  The  frame  is  then  removed  to  the  greatest 
distance  at  which  the  individual  wires  still  appear  sharply  defined,  and 
this  is  noted  as  the  far  point  (r).  The  distance  between^  and  r  gives 
the  range  of  accommodation.  The  wires  only  appear  sharply  defined 
when  the  eye  accommodates  itself  perfectly  for  them,  directly  there  is 
the  slightest  deviation  from  this  perfect  accommodation  (the  frame 
being  too  far  from  or  too  near  to  the  eye^,  the  wires  seem  indistinct, 
thickened,  or  as  if  surrounded  by  a  halo ;  or  coloured  double  images 
of  them  may  even  appear  in  the  transparent  intervals.  With  the  test 
types  the  examination  is  still  easier,  the  nearest  point  at  which  No.  1 
(Snellen)  can  be  distinctly  and  comfortably  read  is  measured  and  noted 
as  the  near  point,  and  then  the  furthest  point  (in  an  emmetropic  eye 
No.  I  of  Snellen  should  be  read  up  to  1',  No.  xx  up  to  20')  is  measured 
and  noted. 

4.— MYOPIA. 

It  has  been  already  shown  that  in  myopia  parallel  rays  (emanating 
from  an  object  at  an  infinite  distance)  are  brought  to  a  focus  in  front 
of  the  retina,  and  that  only  sufficiently  divergent  rays  are  united  upon 
the  latter.  This  is  either  due  to  the  antero-posterior  axis  of  the  eye- 
ball being  too  long,  or  to  the  refracting  power  of  the  eye  being  too 


MYOPIA.  507 

high.  In  order  somewhat  to  improve  their  sight  for  distant  objects, 
short-sighted  persons  nip  their  eyelids  slightly  together.  They  in  this 
way  diminish  the  size  of  the  circles  of  diffusion  by  narrowing  the 
palpebral  apertnre,  and  also  render  the  eye  slightly  less  myopic  by  the 
pressure  which  is  thus  exerted  upon  the  eyeball. 

The  anterior  chamber  is  generally  somewhat  deeper,  and  the  pupil 
somewhat  larger  in  the  myopic  than  in  the  emmetropic  eye.  If  the 
myopia  is  considerable  in  degree,  the  eyeball  appears  abnormally  large 
and  prominent,  the  lids  are  widely  apart,  and  the  lateral  movements  of 
the  eye  somewhat  curtailed.  The  increase  in  the  length  of  the  eye- 
ball, and  the  squarely  ovoid  shape  of  its  posterior  portion  can  be  easily 
recognised  when  the  eye  is  turned  far  inwards  towards  the  nose,  the 
little  hollow  which  exists  in  the  emmetropic  eye  between  the  outer 
canthus  and  the  globe  having  disappeared. 

Myopia  is  frequently  congenital,  and  often  hereditary,  and  its 
existence  may  also  be  sometimes  traced  back  through  several  gene- 
rations, increasing  perhaps  somewhat  in  degree  in  each  successive 
generation.  It  may  also  occur  in  several  members  of  the  same 
family. 

The  most  frequent  cause  of  myopia  is  an  abnormal  increase  in  the 
length  of  the  eyeball  in  its  antero-posterior  axis.  This  extension  occurs 
chiefly  at  the  posterior  portion  of  the  globe,  and  may  give  rise  to  a 
more  or  less  considerable  ovoid  bulging  (posterior  staphyloma),  which 
is  accompanied  by  thinning  and  atrophy  of  the  choroid  and  sclerotic 
(vide  the  article  on  Sclerotico- Choroiditis  Posterior,  p.  427).  But  even 
if  this  should  not  be  present,  the  ophthalmoscope  often  reveals  a 
hypereemic  and  congested  condition  of  the  optic  nerve  and  retina, 
especially  if  the  eyes  have  been  much  overworked  by  artificial  light. 

It  is  also  supposed  by  some,  that  long-continued  work  at  near 
objects  may  produce  myopia.  For  persons  thus  employed,  continually 
accommodate  for  a  very  near  point,  their  crystalline  lens  has,  therefore, 
constantly  to  assume  a  more  convex  form,  and  after  a  time,  it  may  not 
be  able  quite  to  regain  its  original  form,  even  when  the  necessity  for 
adjusting  itself  for  near  objects  no  longer  exists.  The  eye  has  in  fact 
become  somewhat  myopic. 

The  production  and  increase  of  myopia  by  continuous  use  of  the 
eyes  at  near  objects,  appear  to  find  their  explanation  chiefly  in  the  fact 
that  the  inner  tunics  of  the  eyeball  become  congested.  The  near 
approach  of  the  object  necessitates  a  strong  convergence  of  the  optic 
axes,  which  causes  an  accumulation  of  blood  in,  and  congestion  of,  the 
inner  tunics  of  the  eyeball,  these  conditions  being  increased  still  more 
by  the  stooping  position  generally  indulged  in  during  such  employment. 
We  can  easily  understand  that  this  congestion  and  augmentation  in  the 
pressure  of  the  ocular  fluids  must,  if  long  continued,  necessarily  lead 


508  ANOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

to  an  extension  of  the  tunics  at  the  posterior  pole,  and  thus  give  rise 
to  posterior  staphyloma. 

The  seeds  of  short-sightedness  are  frequently  sown  in  childhood, 
either  through  a  premature  over-exertion  of  the  eyes  at  near  objects, 
or  through  some  affection  of  the  refractive  media  (the  cornea  or  lens). 
The  cornea  may,  for  instance,  be  clouded,  and  then  the  patient  often 
brings  the  object  very  close  to  the  eye,  in  order  to  obtain  larger  and 
more  distinct  retinal  images,  and  thus  myopia  may  be  soon  induced. 
The  same  thing  may  occur  when  the  lens  is  somewhat  opaque ;  thus 
it  is  well  known  that  lamellar  cataract  frequently  becomes  complicated 
with  short  sight. 

There  can  be  no  doubt  that  the  degree  of  myopia  is  often  greatly 
increased  during  childhood  by  long  continued  study,  more  especially 
by  insufficient  illumination  and  a  faulty  construction  of  the  tables  or 
desks  at  which  the  pupils  read  and  write.  An  insufficient  illumination 
necessitates  a  close  approximation  of  the  object,  which  gives  rise  to 
straining  of  the  accommodation  and  congestion  of  the  eyes.  A  faulty 
construction  of  the  tables,  or  of  the  distance  between  the  latter  and  the 
seats,  is  also  injurious  by  forcing  the  children  to  stoop.  An  interesting 
and  valuable  monograph  has  been  written  by  Dr.  Cohn*  upon  this 
subject.  He  examined  the  eyes  of  10,060  school  children,  and  could 
distinctly  trace  the  increase  in  the  proportion  of  the  myopia  according 
to  the  construction  of  the  desks  and  the  lighting  of  the  schooj-rooms. 

It  was  formerly  supposed  that  increased  convexity  of  the  cornea 
was  the  cause  of  myopia,  but  this  is  erroneous,  for  Bonders  has  found 
that  the  cornea  is  as  a  rule  less  convex  in  myopic  persons  than  in  the 
emmetropic.  Increase  of  the  curvature  of  the  cornea  (as  in  conical 
cornea)  may,  however,  give  rise  to  myopia.  We  sometimes  also  find 
that  persons  suffering  from  incipient  cataract  become  somewhat  myopic, 
and  see  better  at  a  distance  with  concave  glasses.  The  real  explana- 
tion of  this  fact  is  still  uncertain,  but,  it  may  perhaps  be  due  to  a 
slight  swelling  (?)  of  the  lens,  and  a  consequent  increase  in  its  power 
of  refraction. 

The  diagnosis  of  myopia  is  generally  a  matter  of  no  difficulty.  The 
far  point  of  distinct  vision  is  more  or  less  approximated  to  the  eye,  in 
consequence  of  which  distant  objects  cannot  be  clearly  distinguished, 
and  a  suitable  concave  lens  is  required  to  render  them  distinctly  per- 
ceptible. We  must  be  upon  our  guard,  however,  not  at  once  to 
pronounce  a  person  short-sighted  because  he  holds  small  objects  (such 
as  small  print)  very  close  to  the  eye,  or  because  he  cannot  see  well  at 
a  distance,  for  we  shall  hereafter  point  out  that  this  may  also  occur  in 
hypermetropia,  in  which  case  convex  and  not  concave  glasses  are 
required  to  remedy  this  defect. 

*  Dr.  Cohn,  Untersuchung  der  Avigen  von  10,060  Schulkindern.     Leipsic,  1867. 


MYOPIA. 


509 


Togethei'  with  the  myopia  there  is  frequently  present  more  or  less 
amblyopia  or  weakness  of  sight.  This  is  especially  the  case  if  there  is  a 
considerable  degree  of  sclerotico-choroiditis  posterior,  and  appears  to 
be  chiefly  due  to  the  stretching  of  the  inner  tunics  of  the  eye,  more 
especially  of  the  light  conducting  elements  of  the  retina.  The  impair- 
ment of  sight  may  also  be  due  to  opacities  in  the  vitreous  humour  or 
the  lens.  Myopic  eyes  are  often  very  irritable,  so  that  prolonged  use  in 
reading  or  writing  causes  them  to  become  i-ed,  hot,  and  very  painful. 
This  may  be  partly  due  to  irritability  and  congestion  of  the  inner 
tunics,  or  it  may  be  caused  by  a  weakness  of  the  internal  recti  muscles, 
which  are  not  sufficiently  strong  to  maintain  the  requisite  degree  of  con- 
vergence. If  this  insufficiency  is  developed  to  a  considerable  degree,  it 
gives  rise  to  marked  symptoms  of  asthenopia  and  fatigue  of  the  eyes 
(vide  the  article  on  Muscular  Asthenopia).  We  may  easily  distinguish 
simple  myopia  from  that  complicated  vriih  amblyopia,  by  the  fact  that 
the  former  can  be  completely  corrected  by  suitable  concave  glasses. 
The  less  the  concave  glasses  correct  the  myopia,  the  greater  is  the 
degree  of  the  co-existing  amblyopia,  and  vice  versa. 

Oplithalnioscopic  diagnosis  of  Myopia. — We  may  also  recognise  the 
existence  of  myopia,  and  ascertain  its  approximative  degree,  by  means 
of  the  ophthalmoscope,  and  this  will  often  be  found  very  useful  in 
practice,  particularly  when  the  patient's  statements  are  not  very  trust- 
worthy. We  can  diagnose  the  existence  of  myopia  by  the  following 
appearances : — 

I.  If  we  examine  a  highly  myopic  eye  in  the  erect  image  (that  is 
merely  w^ith  the  mirror,  without  any  convex  lens  before  it),  we  are  at 
once  struck  by  the  fact,  that  we  can  see  the  details  of  the  fundus  at 
some  distance  from  the  eye.  If  we  regard  one  of  the  retinal  vessels  or 
the  optic  disc,  and  move  our  head  slightly  to  one  side,  we  notice  that 
the  image  moves  in  the  contrary  direction ;  if  we  move  to  the  right  it 
moves  to  the  left,  and  vice  versa,  so  that  we  obtain  a  reverse  image  of 
the  background  of  the  eye. 

Fig.  69. 


Fig.  69  will  at  once  explain  the  reason  of  this.  Let  a  be  a  very 
short-sighted  eye  (»t  =  j),  and  h  the  eye  of  the  observer:  «  being  in 
a  state  of  rest  is  adjusted  for  its  far  point  (c),  which  lies  4"  in  front  of 
the  eye.     The  rays  from  the  fundus,  therefore,  pass  out  of  the  eye  in  a 


510     ANOMALIES  OF  REFRACTION  AND  ACCOMMODATION. 

strongly  convergent  direction,  and  meet  at  e,  and,  crossing  there,  fall 
in  a  divergent  direction  upon  the  eye  of  the  observer.  If  the  latter  be 
myopic  (accommodated  for  divergent  rays  when  his  eye  is  in  a  state  of 
rest),  they  may  be  united  upon  his  retina  (h)  without  the  aid  of  any 
correcting  lens  behind  the  ophthalmoscope.  But  if  his  eye  is  emme- 
tropic he  will,  if  adjusted  for  his  far  point,  require  a  suitable  convex 
lens  behind  the  min-or,  in  order  to  render  the  divergent  rays  parallel. 
If  he,  however,  accommodates  himself  for  a  sufficiently  near  point,  he 
will  be  able  to  unite  the  divergent  rays  upon  his  retina  without  any 
correcting  lens.  The  reversed  image  of  the  eye  represented  in  Fig.  69 
(the  myopia  of  which  =  I)  will  be  seen  at  a  distance  of  about  7" — 8", 
because  as  the  rays  from  it  cross  at  c,  the  upper  ray,  e,  becomes  the 
lower  ray  after  they  have  crossed,  and  the  lower  ray,  d,  becomes  the 
upper. 

II.  In  order  to  examine  a  myopic  eye  in  the  erect  image,  it  will  be 
necessary  to  place  a  suitable  concave  lens  behind  the  min'or,  so  as  to 
obtain  a  distinct  image  of  the  fundus ;  the  greater  the  myopia  the 
stronger  must  this  concave  glass  be,  and  the  nearer  must  the  observer 
approach  to  the  eye.  The  strength  of  this  correcting  concave  lens  will 
also  enable  us  approximately  to  estimate  the  degree  of  the  myopia,* 
which  will  be  always  somewhat  less  than  the  strength  of  the  correcting 
lens.  The  field  of  vision  will  appear  smaller,  and  the  image  nearer  the 
eye  of  the  observer,  than  in  the  emmetropic  eye.  The  image  is  also  less 
bright  in  colour  and  less  illuminated,  but  apparently  larger,  for  we 
cannot,  as  in  the  emmetropic  eye  (the  size  of  the  pupil  being  equal) 
overlook  the  whole  expanse  of  the  optic  disc  at  a  glance,  but  only  a 
portion  of  it.  In  the  indu'ect  mode  of  examination,  the  image  of  the 
disc  will  be  less  than  that  of  the  emmetropic  eye,  on  account  of  its 
being  formed  nearer  to  the  object  lens. 

Myopia  may  run  a  very  variable  course.  In  some  cases  its  progress 
is  marked  and  rapid,  in  others  slow  and  insidious ;  in  the  most  favour- 
able cases  it  remains  stationary  at  the  adult  age.  It  is  generally,  how- 
ever, somewhat  progressive,  especially  between  the  ages  of  15  and  26,  and 
often  markedly  so  in  hereditary  myopia,  or  if  the  patients  employ  their 
eyes  a  great  deal  in  reading,  sewing,  etc.  A  moderate  degree  of 
stationary  or  but  slowly  progressive  myopia  causes  but  little  annoyance 
to  the  patient ;  but  it  is  very  different  if  its  degree  is  very  considerable 
and  its  progress  marked  and  rapid,  for  in  the  latter  case  it  is  almost 
always  accompanied  by  symptoms  of  irritation  and  inflammation  of  the 
inner  tunics  of  the  eyeball,  giving  rise  to  redness,  heat,  and  ciliary 
neuralgia  during  prolonged  work  at  near  objects. 

*  For  a  very  full  and  valuable  explanation  of  the  determination  of  the  state  of 
refraction  by  the  aid  of  the  ophthalmoscope,  I  must  refer  the  reader  to  Mauthner's 
Lohrbuch  dor  Ojjhthalmoscopie. 


MYOPIA.  511 

It  is  of  consequence,  both  in  the  prognosis  and  treatment  of  myojDia, 
carefully  to  Avatch  its  progress,  and  accurately  to  ascertain  and  note  the 
degree  of  myopia  at  the  commencement,  so  that  we  may  hereafter  be 
able  to  determine  whether  the  disease  has  remained  stationary  or  pro- 
gressed, and  in  the  latter  case,  to  know  the  extent  and  rate  of  such 
progress. 

The  popular  idea  that  myopia  diminishes  with  old  age  is  not  quite 
correct,  although  it  is  true  that  distant  vision  is  somewhat  improved 
by  the  diminution  in  the  size  of  the  pupil.  Moreover  the  senile  changes 
(sclerosis)  in  the  lens  may  slightly  diminish  the  myopia. 

With  regard  to  the  prognosis  of  short  sight,  it  may  be  stated  that 
there  is  nothing  to  be  feared  from  a  slight  stationary  myopia;  but  it  is 
very  different  when  the  latter  is  high  in  degree,  progressive,  and  asso- 
ciated with  considerable  sclerotico- choroiditis  posterior,  for  then  it  is 
always  a  source  of  danger  to  the  eye.  There  is  a  popular  fallacy  that 
shoi"t-sighted  eyes  are  particularly  strong,  and  even  some  medical  men 
participate  in  it.  But  this  is  quite  erroneous,  indeed  a  myopic  eye 
must  be  looked  upon  as  unsound,  more  especially  if  the  disease  is  exten- 
sive and  progressive.  In  such  cases  care  must,  therefore,  be  taken  that 
the  patient  avoids  all  employment  or  amusement  that  may  hasten  the  pro- 
gress of  the  myopia,  or  give  rise  to  irritation  and  straining  of  the  eye. 

It  is  of  much  consequence  in  myopia  that  the  spectacles  should  be 
selected  with  accuracy  and  care,  for  if  they  are  unsuitable,  more  espe- 
cially if  they  are  too  strong,  they  may  prove  very  injuiious  to  the  eye. 
The  proper  strength  is  rapidly  and  easily  found  in  the  following 
manner : — 

The  degree  of  the  myopia  must  in  the  first  place  be  ascertained  with 
exactitude,  by  trying  the  furthest  distance  at  which  the  patient  can 
read  'No.  1.  If  he  can  do  so  up  to  10"  from  the  eye,  his  far  point  (r) 
lies  at  10",  and  his  myopia  =  ^  ;  for  a  concave  lens  of  10"  focus 
would  enable  him  to  see  at  an  infi.nite  distance,  as  it  would  give  to 
parallel  rays  a  divergence  as  if  they  came  from  a  point  10"  in  front  of  the 
lens  (the  patient's  far  point).  The  position  of  r,  therefore,  always 
affords  us  a  clue  to  the  number  of  the  concave  lens  required,  but 
although  No.  10  would  be  theoretically  the  proper  glass,  we  find  practi- 
cally that  it  would  be  somewhat  too  strong.  The  reason  of  this  is,  that 
the  convergence  of  the  optic  axes  at  10"  prevents  the  eye  from  exactly 
accommodating  itself  for  its  far  point,  the  latter  being  only  attainable 
when  we  look  at  distant  objects  with  parallel  optic  axes.  Hence  con- 
cave 11  or  12  would  be  the  glass  really  suitable.  Whether  a  given  lens 
is  accurately  suited  to  the  patient's  sight,  can  be  easily  determined  in 
the  following  manner : — Let  us  return  to  the  case  above  referred  to  of 
a  myopia  =  J^.  With  concave  10  the  patient  is  able  to  read  No.  xx 
of  Snellen  at  20',  hence  his  V  =  1.     In  order  to  determine  whether 


512  ANOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

No.  10  is  exactly  the  rigM  glass,  we  alternately  place  before  it  weak 
concave  and  convex  glasses  and  try  tlieir  effect.  If  weak  concave 
glasses  improve  the  sight,  the  original  lens  (No.  10)  is  too  weak ;  if,  on 
the  other  hand,  weak  convex  glasses  improve  it,  it  is  too  strong. 
If  neither  concave  nor  convex  glasses  render  any  improvement,  the 
original  lens  suits  exactly.  The  proper  glass  can  be  easily  found  by 
a  very  simple  calculation  ;  for  if  the  myopia  =:  ^,  and  convex  50 
improves  the  sight  still  more  (convex  40  making  it  worse),  the  original 
glass  is  somewhat  too  strong,  and  we  must  deduct  -jL  from  it.     The 

proper  glass  will  be  — ,  for  —  —  —  =  —  .  We  try  concave  13 
^    ^      ^  12-^  10         60         12i  ^ 

and  find  that  neither  concave  nor  convex  glasses  render  any  improve- 
ment. 

If  the  original  lens  (x^)  was  most  improved  by  the  addition  of 
concave  50,  it  was  too  weak,  and  a  concave  lens  of  about  9  inches  focus 

111 

will  be  required  for  T7)  +  ^  ~  oi 

As  a  general  rule,  the  weakest  glass  which  neutralizes  the  myopia 
may  be  given. 

If  a  myope  desires  to  have  spectacles  to  enable  him  to  see  at  a 
distance  of  about  2  feet  (for  reading  music,  etc.),  the  proper  glasses  can 
be  easily  found  by  the  following  calculation  : —  If  his  myopia  =  y  ^ ,  and 
he  wishes  to  see  distinctly  at  24"  the  formiila  will  be  —  -y\  +  -ij  =  — 
2  J,  and  concave  24  will  be  the  proper  glass. 

The  degree  of  the  patient's  range  of  accommodation  materially 
influences  the  choice  of  spectacles,  and  the  question  as  to  whether  or 
not  he  may  be  allowed  their  use  for  reading,  writing,  etc. 

The  range  of  accommodation  may  be  tested  in  the  manner  already 
described,  by  finding  the  nearest  and  furthest  point  at  which  No.  1 
can  be  read  with  ease,  and  then  deducting  the  latter  from  the  former 

according  to  the  formula  _  =^  -    —  _ 
^  APR. 

The  following  plan,  recommended  by  Bonders,  is  however  still  better, 
as  it  allows  the  patient  really  to  accommodate  for  his  far  point.  The 
myopia  having  been  neutralized  by  the  proper  concave  glasses,  so  that 
the  patient  can  read  No.  xx  at  20',  the  position  of  his  near  point 
(with  these  glasses)  is  now  foiind,  if  it  lies  at  5",  his  range  of  accom- 
modation =  -,  for  as  r  =  00 ,  and  p  5",  -  =  -  —  —  =  _ 
5  '  ^         A        5        °o        5. 

In  determining  the  degree  of  myopia,  each  eye  should  always  be 
tested  separately,  for  the  degree  generally  varies  somewhat  (often 
considerably)  in  the  two  eyes.  The  question  as  to  what  glasses  should 
be  given  when  there  is  any  mai'ked  diflerence  in  the  two  eyes,  either  in 


MYOPIA.  51o 

the  degree  of  myopia,  or  in  the  refraction  itself  (the  one  eye  being 
perhaps  myopic,  the  other  hj'jjermetropic)  will  be  considered  hereafter. 

There  is  no  harm  in  permitting  myopic  persons  to  wear  such 
glasses  for  distance,  as  just  neutralize  their  myopia,  especially  if  the 
degi'ce  of  short  sight  is  but  moderate.  If  the  patient  is  young,  the 
myopia  slight,  and  his  range  of  accommodation  good,  he  may  even  bo 
permitted  to  wear  these  glasses  in  reading  and  writing,  as  in  such  cases 
the  myopia  shows  but  little  tendency  to  increase.  But  if  the  latter  is 
considerable,  the  range  of  accommodation  diminished,  and  the  acute- 
ness  of  vision  impaired,  the  myopia  should  not  be  quite  neutralized. 
The  patient  may,  however,  use  a  binocular  concave  eye-glass  before  his 
spectacles  when  he  desires  to  see  distant  objects  very  distinctly.* 

For  the  purpose  of  reading  music,  I  think  it  best  to  give  patients 
spectacles  suited  for  a  distance  of  2' — 3',  for  if  the  myopia  is  con- 
siderable, and  they  use  glasses  which  completely  neutralize  it  for 
distance,  the  size  of  the  music  is  inconveniently  diminished,  and  thus 
becomes  somewhat  indistinct  and  difficult  to  decipher. 

We  now  come  to  the  question  whether  myopic  persons  should  wear 
glasses  in  reading,  sewing,  writing,  etc.,  and  the  answer  to  this  must 
depend  upon  several  circumstances. 

Where  the  myopia  is  but  slight  in  degree  (less  than  -^),  they  may 
be  dispensed  with — or,  if  the  employment  is  not  continued  for  any  length 
of  time,  the  distance  glasses  may  even  be  worn,  but  the  type  must  be 
held  at  a  greater  distance,  otherwise  the  eye  becomes  fatigued,  and  the 
accommodation  strained.  Indeed,  I  find  that  it  is  less  trying  and  more 
comfortable  for  such  patients  to  read  without  their  glasses. 

If  the  myopia  is  considerable  in  degree,  so  that  the  print  has  to  be 
held  very  close  to  the  eye,  glasses  should  be  prescribed  which  will  remove 
the  far  point  to  about  14" — 16",  for  this  will  prevent  the  necessity 
of  stooping,  which  causes  an  increased  flow  of  blood  to  the  eye,  and  an 
increase  in  the  tension  of  the  intra-ocular  fluids.  This  congestion  of 
the  eye  greatly  tends  to  promote  the  develojjment  of  sclerotico-cho- 
roiditis  posterior,  intra-ocular  haemorrhage,  and  detachment  of  the 
retina,  which  are  so  apt  to  occur  in  very  short-sighted  persons.  For 
these  reasons,  we  should  direct  myopes  to  read  with  their  heads  well 
thrown  back,  and  to  write  at  a  sloping  desk.  Strict  injunctions  must 
also  be  given  against  the  habit  of  reading  in  the  recumbent  position, 
either  in  bed  or  on  a  couch,  as  this  produces  great  congestion  of  the 
eyes. 

But  the  strong  convergence  of  the  optic  axes  which  takes  place 

*  In  very  higli  dcgi-ees  of  myopia,  I  hare  found  Stein  hell's  glass-cone  very  useful 
for  distant  objects,  as  it  acts  like  a  G-alilcau  telescope.  It  consists  of  a  smaU  cone 
of  solid  glass,  the  base  of  wliich  is  convex,  and  the  o^oposite  surface  concave.  It  is 
about  one  inch  in  length,  and  can  be  readily  carried  in  the  waistcoat  pocket. 

2    L 


514  ANOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

wlieu  the  object  has  to  be  held  close  to  the  eye,  is  also  a  source  of  great 
danger,  for  it  is  always  accompanied  by  an  increased  tension  of  the 
eyeball  and  of  the  accommodation.  The  latter  is  an  associated  action, 
not  arising  from  the  mechanism  of  the  convergence,  but  existing  within 
the  eye  itself,  and  may,  consequently,  easily  give  rise  to  an  increase  of 
the  myopia.  But  besides  this,  the  pressure  of  the  muscles  upon  the 
eyeball  is  greater  when  the  optic  axes  are  convergent  than  when  they 
are  parallel,  and  this  increase  of  pressure  must  tend  to  give  rise  to  the 
development  of  posterior  staphyloma,  and  to  hasten  its  progress.  The 
increase  in  the  tension  of  the  eyeball  is  particularly  marked  when  the 
internal  recti  muscles  are  weak,  and  thus  render  the  convergence  of 
the  optic  axes  more  difficult. 

Now  if  we  afford  such  very  short-sighted  persons  the  use  of  glasses 
which  enable  them  to  read  and  write  at  a  distance  of  14  or  16  inches 
from  the  eye,  we  do  away  with  the  necessity  of  a  considerable  con- 
vergence of  the  optic  axes,  the  stooping  position,  and  the  e"vils  to  which 
these  give  rise. 

But  the  patient  must  be  warned  not  to  bring  the  type  close  to  him 
when  the  eyes  become  a  little  tired,  for  this  would  strain  and  fatigue 
the  accommodation ;  but  the  book  should  then  be  laid  aside  for  a  few 
minutes,  and  the  eyes  rested. 

Spectacles  may  also  be  used  for  near  objects  in  those  cases  in  which 
the  myopia  is  accompanied  by  muscular  asthenopia  (depending  upon 
an  insufficiency  or  weakness  of  the  internal  recti  muscles),  which  mani- 
fests itself  as  soon  as  the  patient  has  worked  at  near  objects  for  a 
short  time. 

Whilst  the  use  of  spectacles  for  near  objects  may  be  permitted  with 
advantage  in  the  above  forms  of  myopia,  it  must  be  forbidden  if  the 
rano-e  of  accommodation  is  very  limited,  and  if  the  patients  suffer  from 
such  a  degree  of  amblyopia  (generally  depending  upon  sclerotico- cho- 
roiditis posterior),  that  they  are  unable  to  read  No.  2  or  3  of  Snellen's 
types.  The  glasses  will  diminish  the  size  of  the  letters,  and,  in  order 
to  see  them  under  a  larger  visual  angle,  the  patient  will  bring  the  object 
very  close  to  the  eye,  which  will  cause  the  accommodation  to  be  greatly 
strained,  the  intra-ocular  tension  to  be  increased,  and  serious  mischief 
will  but  too  surely  ensue.  Spectacles  should  not,  therefore,  be  per- 
mitted for  near  objects  when  marked  amblyopia  exists. 

If  the  myopia  is  very  considerable,  we  generally  find  that  only  one 
eye  is  employed  for  near  objects ;  the  convergence  of  the  optic  axes 
bcino-  therefore  annulled.  Bonders  says  with  refei^ence  to  this  point, 
"  Tfiis  appears  to  me  to  be  often  a  desirable  condition  :  in  strong  myopia 
binocular  vision  loses  its  value,  and  the  tension  which  would  be  required 
for  it  cannot  be  otherwise  than  injurious.  Now,  in  such  cases,  for 
reading  no  spectacles  are  given ;  in  the  first  place,  because  the  acute- 


PRESBYOPIA.  515 

ness  of"  vision  has  usually  somewlm t  decreased,  aud  the  diminution  of 
concave  glasses  is  now  troublesome;  in  the  second  place,  because,  with 
the  retrocession  of  r,  injurious  efforts  at  convergence  and  at  binocular 
vision  might  be  excited.  In  any  case  the  spectacles  should  be  so  weak 
as  to  avoid  these  results." 

5.— PRESBYOPIA. 

The  first  symptom  of  presbyopia  is  that  small  objects  (small  type,  tine 
needlework,  etc.)  cannot  be  seen  with  such  ease  or  at  so  short  a  distance 
as  before.  In  order  to  see  minute  objects  more  distinctly,  the  patient  is 
obliged  to  remove  them  further  from  the  eye,  or  even  to  seek  a  bright 
light,  so  as  to  diminish  the  circles  of  diffusion  upon  the  retina  by  nar- 
rowing the  size  of  the  pupil.  But  as  the  retinal  images  of  these  fine 
objects  are  very  small,  on  account  of  the  distance  at  which  they  are 
held,  he  will  soon  experience  a  commensurate  difficulty  in  clearly  dis- 
tinguishing them,  the  print,  for  instance,  will  get  indistinct  and  con- 
fused, and  the  eyes  become  fatigued  and  painful. 

In  simple  presbyopia,  the  far  point  is  at  a  normal  distance  fi'oni  the 
eye,  parallel  rays  are  united  upon  the  retina,  and  neither  concave  nor 
convex  glasses  (even  after  the  instillation  of  atropine)  at  all  improve 
distant  vision.  The  eye  is  neither  myopic  nor  hypermetropic.  There 
is  in  fact  no  anomaly  of  refraction,  but  only  a  narrowing  of  the  range 
of  accommodation  ;  the  near  point  is  removed  too  far  from  the  eye, 
and  hence  the  difficulty  of  accurately  distinguishing  small  objects. 

Amblyopia  sometimes  co-exists  with  presbyopia,  and  may  even  be 
mistaken  for  it,  as  the  amblyopic  patient  likewise  cannot  see  very  small 
objects  distinctly,  and  convex  glasses  also  improve  his  sight.  But  in 
simple  presbyopia  (uncomplicated  with  amblyopia)  we  should  be  able 
to  restore  the  normal  acuity  of  vision  and  range  of  accommodation 
by  the  proper  convex  glass.  With  its  aid,  the  patient  should  be  able  to 
read  No  1  at  8" ;  hence  if  he  can  only  decipher  No.  2  or  No.  4,  or  is 
obliged  to  hold  the  print  closer,  he  is  also  amblyopic. 

Bonders  has  found  that  in  the  emmetropic  eye  the  near  point 
gradually  recedes,  even  from  an  early  age,  further  and  further  from  the 
eye.  This  recession  commences  about  the  age  of  10,  and  progresses 
regularly  M-ith  increasing  years.  At  40  it  lies  at  about  8",  at  50,  at  11" 
— 12,"  and  so  on.  In  the  emmetropic  eye,  no  inconvenience  is  generally 
ox^^srienced  from  this  recession  till  about  the  age  of  40  or  45.  This 
change  in  the  position  of  the  near  point  is  met  with  in  all  eyes, — the 
emmetropic,  hypennetropic,  and  myopic. 

But  the  far  point  also  begins  in  the  normal  eye  to  recede  somewhat 
about  the  age  of  50,  so  that  the  eye  then  becomes  slightly  hypermetro- 
pic (distant  vision  being  improved  by  convex  glasses).     At   70  or  80 

2  L  2 


516  ANOMALIES  OF   REFRACTION   AND   ACCOMMODATION. 

years  of  age,  tlie  liy|3ermetropia  may  =  ~,  i.e.,  the  patient  can  see 
distinctly  at  a  distance  with  a  convex  glass  of  24"  focus.  This  hyper- 
metropia,  which  is  at  first  only  acquired,  may  afterwards  become  abso- 
lute ;  so  that  the  patient  is  not  only  unable  to  accommodate  for  diver- 
gent, but  even  for  parallel  rays. 

The  recession  of  the  near  point  from  the  eye,  and  the  consequent 
narroAving  of  the  range  of  accommodation,  are  far  more  due  to  a  change 
in  those  parts  within  ihe  eye  which  are  passively  changed  during  the 
act  of  accommodation,  than  to  an  alteration  in  those  which  through 
their  activity  bring  about  the  latter.  For  the  ciliary  muscle,  the 
active  agent  of  accommodation,  is  generally  normal,  although  it  may, 
later  in  life,  undergo  senile  changes.  Whereas,  the  passively  changed 
organ  of  accommodation,  the  crystalline  lens,  gradually  becomes  more 
and  more  firm  with  advancing  years,  and  in  consequence  of  this 
increased  firmness,  the  same  amount  of  muscular  action  cannot  produce 
the  same  change  in  the  form  of  the  lens  as  heretofore. 

At  first,  of  course,  no  inconvenience  is  experienced  from  this  gradual 
recession  of  the  near  point ;  we  do  not,  in  fact,  notice  it  until  the  dis- 
tance is  so  considerable  that  we  cannot  easily  distinguish  small  objects. 
When  are  we,  then,  to  consider  an  eye  presbyopic  ?  Donders  thinks 
this  should  be  done  as  soon  as  the  near  point  has  receded  further  than 
8"  from  the  eye ;  for  as  soon  as  this  is  the  case,  patients  generally  begin 
to  complain  that  continued  work  at  small  objects  has  become  irksome 
and  fatiguing.  We,  however,  sometimes  meet  with  persons  with  very 
strong  sight,  who  can  read  and  write  for  hours  without  experiencing 
any  inconvenience,  even  although  their  near  point  may  be  11" — 12" 
from  the  eye.  Bat  these  cases  are  exceptional.  Let  us,  therefore,  with 
Donders,  consider  presbyopia  to  begin  when  the  near  point  is  removed 
further  than  8"  from  the  eye. 

The  degree  of  presbyopia  (Pr)  maybe  easily  found  if  we  decide  upon 
a  definite  distance  {e.g.,  8")  as  the  commencement  of  presbyopia,  for  we 
have  then  simply  to  deduct  the  presbyopic  near  point  (p')  from  this. 
Thus  if  p'  lies  at  16"  the  presbyopia  =  y^^,  for  ^  —  ^  =.  -^.  Hence 
convex  16  will  neutralize  the  presbyopia  and  bring  the  near  point  again 
to  8". 

It  will  perhaps  have  already  struck  the  reader,  that  if  presbyopia  is 
assumed  to  commence  when  the  near  ]3oint  has  receded  further  than  8" 
from  the  eye,  not  only  the  emmetropic,  but  also  the  myopic  and  hyper- 
metropic, eye  may  suffer  from  presbyopia ;  for  if  a  person  has  a  myopia 
=  ^,  and  his  near  point  lies  at  12",  he  is  also  presbyopic.  This 
cannot,  of  course,  occur  when  the  myopia  is  higher  in  degree  than  -|-. 
In  hypermetropia  the  same  thing  may  take  place,  for  if,  with  the  convex 
glass  which  neutralizes  the  hypermetropia,  the  near  point  hes  at  12", 
there  is  also  presbyopia. 


HYPERMETROPIA.  517 

The  rangfe  of  accommodation  is  found  by  the  formula  —  =  —  —   — • 
°  •'APR 

If  p  =  10",  and  r    =    oo  —  =   — ,  for    ,—   ~    —    =  — 
^  '  A         10  10  CO         10 

There  can  be  no  qiiestion  as  to  the  advisabiHty  and  necessity  of  per- 
mitting far-sighted  jDcrsons  the  use  of  spectacles.  They  should  be 
furnished  with  them  as  soon  as  they  are  in  the  slightest  degree  annoyed 
or  inconvenienced  by  the  presbyopia.  Some  medical  men  think  that 
presbyopic  patients  should  do  without  spectacles  as  long  as  possible, 
for  fear  that  the  eye  should,  even  at  an  early  pei-iod,  get  so  used  to  them 
as  to  find  them  indispensable. 

This  is,  however,  an  error,  for  if  such  persons  are  permitted  to 
work  without  glasses,  Ave  observe  that  the  presbyopia  soon  rapidly 
increases. 

The  proper  strength  of  the  glasses  may  be  readily  calculated.  If  p 
(the  near  point)  lies  16"  from  the  eye,  Pr  =  -|-  —  iV  ^^  tV-  -^  convex 
glass  of  16"  focus  will  bring  the  near  point  back  again  to  8"  from  the 
eye.  We  must  generally,  however,  give  somewhat  weaker  glasses, 
because,  on  account  of  the  greater  convergence  of  the  optic  axes,  the 
near  point  will  tlu-ough  these  glasses  (convex  16)  be  in  reality  brought 
nearer  than  8".  Late  in  life,  when  there  is  some  diminution  in  the 
acuteness  of  vision,  the  near  point  may  sometimes  be  brought  even  to 
G"  or  7",  and  it  should  be  approximated  the  closer  the  greater  the  range 
of  accommodation. 

If  no  hypermetropia  exists,  the  weakest  glasses  with  which  No.  1 
of  Snellen  can  be  distinctly  and  easily  read  at  about  12"  distance,  may 
generally  be  given.  But  I  have  often  found  that  if  the  person  is  much 
employed  in  reading  and  writing,  and  has  always  been  accustomed  to 
hold  his  book  at  a  considerable  distance,  he  will  be  at  first  much  incon- 
venienced if  his  near  point  is  brought  to  10"  or  12".  We  shall,  there- 
fore, have  to  give  him  glasses  which  will  bring  it  only  to  about  16". 
With  these  he  will  be  able  to  work  with  ease  for  a  considerable  length 
of  time.  They  may  afterwards  be  gradually  changed  for  rather 
stronger  ones. 

In  choosing  spectacles  for  far-sighted  persons,  we  must  also  be 
particularly  guided  by  the  range  of  their  power  of  accommodation.  If 
this  is  good,  we  may  give  them  glasses  which  bring  their  near  point  to 
8",  but  if  it  is  much  diminished  weaker  glasses  should  be  chosen,  so 
that  it  may  He  at  10" — 12"  from  the  eye. 

6.— HYPERMETROPIA. 

It  has  already  been  stated  (p.  499)  that  in  hypermetropia  the 
refractive  power  of  the  eye  is  so  low,  or  its   optic   axis   so  short,  that 


518  ANOMALIES   OF   REFRACTION   AND   ACCOxMMODATION. 

when  the  eye  is  in  a  state  of  rest  parallel  rays  are  not  united  upon  the 
retina,  but  behind  it,  and  only  convergent  rays  are  brought  to  a  focus 
upon  the  latter.  We  must,  therefore,  give  to  parallel  rays,  emanating 
from  distant  objects,  a  convergent  direction  by  means  of  a  convex  glass, 
and  the  reader  will  now  comprehend  how  it  is  that  a  hypermetropic 
eye  requires  convex  glasses  for  seeing  distant  objects.  The  patient  may 
require  perhaps  even  a  stronger  pair  for  near  objects.  The  consequence 
of  this  low  refractive  power  of  the  eye  is,  that  whereas  the  normal  eye 
unites  parallel  rays  upon  its  retina  without  any  accommodative  effort, 
the  hypermetropic  eye  has  already,  in  order  to  do  so,  to  exert  its 
accommodation  more  or  less  considerably,  according  to  the  amount  of 
hypermetropia.  This  exertion  increases,  of  course,  in  direct  ratio  with 
the  proximity  of  the  object.  If  the  degree  of  hypermetropia  is 
moderate,  and  the  power  of  accommodation  good,  no  particular  annoy- 
ance is  pei'haps  experienced,  even  in  reading  or  writing.  But  in 
absolute  hypermetropia,  the  patient  will  not  be  able  to  see  well  at  any 
point. 

It  will  be  found  that  hypermetropia  generally  depends  upon  a 
peculiar  construction  of  the  eye.  It  is  smaller  and  flatter  than  the 
emmetropic  eye,  and  although  all  its  dimensions  are  less  than  in  the 
latter,  this  is  more  particularly  and  markedly  the  case  in  the  antero- 
posterior axis.  The  eye  does  not  appear  to  fill  out  the  palpebral  aper- 
ture properly,  but  a  little  space  may  be  observed  between  the  outer 
canthus  and  the  eyeball.  Upon  directing  the  eye  to  be  turned  very 
much  inwards,  it  will  also  be  seen  that  the  posterior  portion  of  the  eye- 
ball is  flatter  and  more  compressed  than  in  the  emmetropic  eye. 
Bonders  considers  that  the  hypermetropic  is  generally  an  imperfectly 
developed  eye,  that  the  expansion  of  the  retina  is  less,  and  that  there 
is  a  smaller  optic  nerve  with  a  less  number  of  fibres.  He  thinks, 
moreover,  that  in  hypermetropia  there  often  exists  a  typical  form  of 
face,  chiefly  dependent  upon  the  shallowness  of  the  orbit,  which  lends 
a  peculiar  flatness  to  the  physiognomy.  The  hypermetropic  construc- 
tion of  the  eyeball  is  congenital,  and  often  hereditaiy. 

The  ophthalmoscope  also  enables  us  to  diagnose  a  hypermetropic 
eye,  but  in  this  case  just  the  reverse  obtains  to  what  was  seen  in  the 
myopic  eye  (page  509). 

I.  The  fundus  may  also  in  this  case  be  seen  in  the  erect  image  at  a 
considerable  distance,  but  we  obtain  an  erect  image  of  it  (and  not  as 
in  myopia  a  reverse  image) ,  for  if  we  regard  the  optic  nerve,  or  one  of 
the  retinal  vessels,  and  move  our  head  to  one  side,  we  find  that  the 
image  moves  in  the  same  direction.  For  an  explanation  of  this  let  us 
glance  at  Fig.  70. 

Let  a  be  the  hypermetropic  eye,  h  the  eye  of  the  observer ;  a  is 
adjusted  for  its  far  point  (convergent  rays),  and  the  rays  reflected  from 


HYPERMETROPIA. 


519 


its    back-ground  will,  consequently,  emanate  from  it  in    a  divergent 
direction,  as  if  they  came  from  a  point  behind  the  retina,  and  they  must, 


therefore,  also  ftxll  in  a  divergent  direction  upon  the  eye  of  the  observer. 
If  the  latter  is  myopic  (adjusted  for  divergent  rays),  the  rays  will  be 
united  upon  his  retina  without  the  aid  of  any  correcting  lens  behind 
the  ophthalmoscope.  But  if  his  eye  is  emmetropic  (adjusted,  when  in 
a  state  of  rest,  for  parallel  rays),  he  will  either  have  to  place  a  convex 
lens  behind  the  mirror,  or  have  to  accommodate  for  a  nearer  point. 
The  strongest  convex  lens  with  which  the  details  of  the  fundus  can 
still  be  seen  in  the  erect  image,  affords  us  a  relative  estimate  of  the 
degree  of  existing  hypermetropia. 

The  image  of  the  observed  eye  will  be  erect,  for  c  and  d  retain  their 
relative  positions. 

II.  On  going  closer,  but  still  examining  in  the  erect  image,  the  field 
of  vision  appears  much  enlarged,  and  the  image  removed  further  from 
the  eye,  its  size  is  considerably  diminished,  whereas  the  intensity  of  its 
light  and  colour  is  much  increased.  If  the  hypermetropia  is  high  in 
degree,  we  can  overlook  at  a  glance  not  only  the  whole  optic  entrance, 
but  also  a  considerable  portion  of  the  fundus  around  it.  In  the  indirect 
mode  of  examination,  the  size  of  the  optic  disc  will  appear  much  laro-er 
than  in  the  emmetropic  eye,  which  is  due  to  its  image  being  formed 
farther  from  the  object  lens.  If  our  eye  is  emmetropic,  we  must,  in 
order  to  gain  a  distinct  image,  either  place  a  strong  convex  lens  behind 
the  mirror,  or  else  we  must  accommodate  for  a  nearer  point. 

The  ophthalmoscopic  diagnosis  of  hypermetropia  is  frequently  of 
much  service,  especially  in  young  children  affected  with  strabismus,  the 
state  of  whose  refraction  we  wish  to  ascertain,  but  who  are  too  youno- 
to  read.  Again,  in  spasm  of  the  ciliary  muscle  dependent  upon  hyper- 
metropia, the  latter  may  be  so  completely  masked  that  the  patient  can 
only  see  at  a  distance  with  slightly  concave  glasses,  and  not  at  all  with 
convex  ones.  We  hence,  perhaps,  believe  it  to  be  a  case  of  myopia,  but 
on  ophthalmoscopic  examination  we  find  that  the  refraction  is  markedly 
hypermetropic.  In  such  cases  the  patient  should,  however,  look  at 
some  distant  object,  or  into  vacant  space,  so  that  his  accommodation 
may  be  quite  relaxed.    We  may  notice  in  such  patients  how  the  ophthal- 


520  ANOMALIES   OF   REFRACTION  AND   ACCOMMODATION. 

moscopic  appearances  vary  when  the  accommodation  is  relaxed,  and 
when  it  is  called  into  action  by  their  regarding  some  near  object. 

We  mnst  distinguish  various  forms  of  hypermetropia,  and  in  our 
classification  of  these  we  shall  follow  Donders'  sj^stem,  which  is  the 
most  practical. 

We  may,  in  the  first  place,  divide  hypermetropia  into  two  primary 
classes,  the  original  and  the  acquired. 

Owing  to  the  senile  changes  in  the  lens  which  appear  with  advanc- 
ing age,  the  far  point  begins  to  recede  somewhat  from  the  eye  at  the 
age  of  40  or  45.  At  60,  the  eye  is  generally  already  so  hypermetropic 
that  distant  vision  is  markedly  improved  by  convex  glasses.  At  70  or 
80  years  the  hypermetropia  often  ^  J^.  Tliis  is  termed  acquired 
hypermetropia.  The  latter  will,  of  course,  be  very  considerable  when 
the  crystalline  lens  is  absent  (as  after  extraction  of  cataract). 

Original  hypermetro]3ia  may  be  divided  into  the  manifest  (Hm)  and 
latent  (HI)  form. 

In  order  to  determine  the  presence  of  hypermetropia,  the  patient  is 
directed  to  read  l!^o.  xx  (Snellen)  at  20'.  Let  us  suppose  that  he  can 
do  so  with  ease ;  we  then  find  the  strongest  convex  glass  with  which  he 
can  still  see  the  same  number  clearly  and  distinctly,  and  this  gives  us 
the  degree  of  manifest  hypermetropia.  If  convex  20  is  the  lens  (convex 
18  making  the  sight  worse)  Hm  =  -~.  Each  eye  should  be  tried 
separately,  as  the  degree  of  hypermetropia  may  vary.  The  range  of 
accommodation  with  this  glass  is  then  tried. 

But  although  convex  20  may  be  the  strongest  glass  with  which  he 
can  see  at  a  distance,  the  degree  of  hypermetropia  may  in  reality  be 
very  much  higher  than  -Jg-.  The  fact  being,  that  the  patient  has  been 
so  accustomed  to  exert  his  accommodation  (even  when  regarding 
distant  objects),  that  he  cannot  relax  it  all  at  once,  even  when  there  is 
no  occasion  for  it,  the  malconstruction  of  the  eye  being  compensated 
for  by  a  convex  lens.  To  find  the  real  degree  of  hypermetropia,  we 
must,  therefore,  paralyse  his  accommodation  by  a  strong  solution  of 
atropine  (gr.  iv  ad  3J).  This  should  be  allowed  to  act  for  two  or  three 
hours.  At  the  end  of  this  time  we  again  examine  the  patient,  and  now, 
perhaps,  find  that  he  cannot  see  No.  xx  at  all  at  20'  without  glasses, 
or  even  with  convex  20.  To  do  so  distinctly  he,  perhaps,  I'equires 
convex  8 ;  and  this  difierence  in  the  power  of  the  glasses  required 
before  and  after  the  paralysis  of  the  ciliary  muscle,  shows  us  to  what 
an  extent  he  exerted  his  accommodation  before  the  application  of  the 
atropine.  But  this  great  difference  only  exists  in  young  persons,  with 
a  good  range  of  accommodation.  The  atropine  should  be  only  applied 
to  one  eye  at  a  time  ;  its  effect  goes  oflP  in  about  six  or  seven  days. 
But  as  its  eflfcct  proves  very  disagreeable  and  confusing  to  the  sight,  it 
should  only  be  applied  in  those  cases  in  which  it  is  of  importance  to  know 


IIYPERMETROPIA.  521 

precisely  the  degree  of  latent  hypermetropia.  Its  action  may,  if  neces- 
sary, be  neutralized  by  the  extract  of  Calabar  bean,  which  will  however 
have  to  be  repeated  several  times,  as  its  effect  is  much  more  transitory. 

A  slight  degree  of  hypei^metropia  is  often  unnoticed  until  the  age 
of  25  or  30,  when  symptoms  of  asthenopia  show  themselves  if  the 
patient  is  obliged  to  work  much  at  near  objects.  If  we  try  the  sight 
for  distance,  we  find  that  he  can  read  No.  xx  at  20',  and  also  with  a 
weak  convex  glass  (30  or  40).  Or,  perhaps,  if  only  moraentarily  held 
before  the  eye  it  makes  the  sight  worse,  as  the  patient  cannot  at  once 
relax  his  accommodation,  but  after  looking  through  it  for  a  few  minutes 
he  sees  better.  To  make  sure  of  the  degree  of  HI,  the  accommodation 
must  be  paralysed  with  atropine. 

Bonders  divides  manifest  hypermetropia  into  three  classes,  the 
facultative,  the  relative,  and  the  absolute. 

In  facultative  hypermetropia  the  patient  can  see  well  (with  parallel 
optic  axes)  at  an  infinite  distance,  with  or  without  convex  glasses.  He 
can  also  see  to  read  small  print  with  ease  without  glasses,  so  that  he 
experiences  no  fatigue  during  work.  Presbyopia,  however,  sets  in 
unusually  early,  and  then  symptoms  of  asthenopia  supervene. 

In  relative  hypermetropia,  the  eye  may  also  be  able  to  accommodate 
itself  either  for  parallel  or  for  divergent  rays,  and  see  well  both  at 
a  distance  and  near  at  hand,  but  it  can  only  do  so  by  converging  the 
optic  axes  for  a  nearer  point  than  that  at  which  the  object  is  situated ; 
by  acquiring,  in  fact,  a  periodic  convergent  squint.  It  is  not  of  very 
frequent  occurrence  in  childhood,  but  is  more  often  met  with  after  the 
age  of  puberty  and  in  early  manhood.  The  sight  is  always  more  or 
less  affected,  and  the  patient  has  a  difficulty  in  finding  the  exact  dis- 
tance at  which  he  can  see  best. 

In  absolute  lnjpermetropia  vision  is  indistinct,  both  for  infinite  dis- 
tance and  for  near  objects ;  for  the  patient  cannot  unite  the  rays  upon 
the  retina  even  with  the  strongest  effort  of  accommodation,  or  with  the 
strongest  convergence  of  the  optic  axes.  The  focus  of  both  divergent 
and  parallel  rays  remains  situated  behind  the  retina.  It  is  not  often  met 
with  in  youthful  individuals,  as  they  generally  possess  a  sufficiently 
strong  power  of  accommodation  to  overcome  it.  In  a  superficial  exami- 
nation, such  a  patient  might  be  mistaken  for  a  person  suffering  from 
myopia  with  amblyopia,  for  he  will  not  be  able  to  see  distinctly  at  a 
distance  without  glasses,  which  may  be  erroneously  attributed  to  myopia, 
nor  Avill  he  be  able  to  read  very  fine  print,  and  this  may  be  supposed  to 
be  due  to  amblyopia. 

If  the  hypermetropia  is  considerable  in  degree,  the  patients  often  see 
better  when  the  print  is  held  very  close  to  the  eye,  than  when  it  is  10" 
or  12"  off".  This  is  partly  due  to  the  diminution  in  the  size  of  the 
circles  of  diffusion,  on  account  of  the  contraction  of  the  pupil.     More- 


522  ANOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

over,  the  chicles  of  diflPusion  increase  comparatively  less  in  magnitude  than 
the  size  of  the  retinal  image,  as  the  object  is  approximated  (Grraefe). 

A  hypermetropic  eye  may  at  a  certain  age  become  presbyopic. 
If  with  the  glasses  which  neutrahze  the  hypermetropia,  the  near  point 
lies  at  12"  to  14",  presbyopia  co-exists,  and  a  stronger  pair  of  glasses 
will  be  required  for  reading. 

The  range  of  accommodation  is  best  found  by  neutralizing  the 
patient's  hypermetropia  by  means  of  the  proper  convex  lens,  and  then 
finding  where  his  near  point  lies  with  this  glass. 

In  high  degrees  of  hypermetropia  the  acuteness  of  vision  is  gene- 
rally somewhat  diminished.  This,  according  to  Bonders,  is  partly 
due  to  the  structure  of  the  eye,  for  as  the  nodal  point  lies  far  back,  the 
retinal  images  will  be  correspondingly  small ;  hence  convex  glasses 
improve  the  sight,  by  advancing  the  nodal  point,  and  increasing  the 
size  of  the  retinal  image.  It  may  also  be  due  to  astigmatism,  or  to  the 
smaller  number  of  nerve  fibres  in  the  optic  nerve  and  retina. 

Hypermetropia  is  a  very  frequent  cause  of  asthenopia  (sen  hebe- 
tude visus,  impaired  vision,  muscular  asthenopia,  etc)  ;  this  condition 
being  distinguished  by  the  following  symptoms  : — The  patient  cannot 
look  at  near  objects  (in  reading,  writing,  sewing,  etc.),  for  any  length 
of  time  without  the  eyes  becoming  fatigued.  The  print  becomes  indis- 
tinct, the  letters  run  into  one  another,  there  is  pain  in  and  around  the 
eye,  and  the  latter  may  become  red  and  watery,  and  feel  hot  and 
uncomfortable ;  yet  the  eye  looks  quite  healthy,  the  refracting  media 
are  clear,  vision  is  good,  the  convergence  of  the  optic  axes  perfect,  and 
the  mobility  of  the  eye  unimpaired.  Neither  does  the  ophthalmoscope 
reveal  anything  abnormal,  except  perhaps  slight  hyperaemia  of  the 
optic  nerve  and  retina.  The  symptoms  of  asthenopia  quickly  vanish 
when  the  work  is  laid  aside,  to  reappear  however  when  it  is  resumed. 
It  was  indeed  a  great  boon  when  Bonders  discovered  that  most  of 
these  cases  of  asthenopia  depended  upon  hypermetropia,  and  could  be 
ciired  by  the  proper  use  of  spectacles.  If  we  wish  permanently  to 
cure  such  cases,  we  must  afibrd  the  patient  the  aid  of  glasses,  and  thus 
prevent  all  undue  straining  of  the  accommodation. 

This  accommodative  form  of  asthenopia  must  be  distinguished 
from  the  muscular,  which  depends  upon  weakness  of  the  internal  recti 
muscles,  and  from  the  retinal  asthenopia.  The  latter  is  generally  due  to 
hyperaesthesia  and.  irritabiUty  of  the  retina,  accompanied  by  hyperaemia 
of  the  optic  nerve  and  retina.  It  mostly  occurs  in  feeble,  nervous, 
and  excitable  persons,  especially  females. 

Let  us  now  consider  how  hypermetropic  persons  are  to  be  suited 
with  glasses. 

Theoretically,  it  would  appear  right  to  neutralize  the  hypermetropia 
by  a  convex  lens,  and  thus  change  the  eye  into  an  emmetropic  one  ;  this 


H  YPERMETROPIA .  523 

lens  forming,  so  to  speak,  an  integral  part  of  the  eye.  Bnt  in  practice 
we  find  tliat  this  does  not  answer. 

In  facultative  hypermetropia,  there  will  be  no  occasion  to  prescribe 
glasses  for  distance,  as  the  patient  can  see  well  without  them.  More- 
over, there  is  the  disadvantage,  that  after  convex  spectacles  have  been 
worn  for  some  time  for  distance,  the  power  of  seeing  distinctly  without 
them  is  lost,  which  is  of  course  very  inconvenient.  For  this  reason  they 
should  never  be  ordered,  except  in  cases  of  absolute  or  relative  hyperme- 
tropia of  a  considerable  degree.  If  there  are  symptoms  of  asthenopia, 
glasses  should  be  given  for  reading,  etc.,  which  are  somewhat  stronger 
than  those  which  cori-ect  the  manifest  hypermetropia.  If  these  are 
found  too  strong  and  trjang  to  the  eye,  they  must  be  exchanged  for 
weaker  ones,  and  the  strength  be  gradually  increased  until  the  asthen- 
opia has  disappeared. 

In  relative  and  absolute  hypermetropia  spectacles  should  also  be 
worn  for  distance,  as  we  find  that  in  such  instances  distant  vision  is  not 
distinct.  In  such  cases,  I  generally  commence  with  the  glasses  which 
neutralize  the  manifest  hypermetropia,  and  in  young  persons  order  them 
to  be  worn  both  for  near  and  distant  objects.  If  they  prove  too  strong  for 
distance,  a  weaker  pair  must  be  prescribed,  and  their  strength  gradually 
increased.  If  they  do  not  relieve  the  asthenopia,  or  if  presbyopia  co- 
exists, a  stronger  pair  must  be  given  for  reading,  writing,  and  sewing. 

In  using  the  spectacles  for  reading,  sewing,  etc.,  it  is  always  advisable 
to  interrupt  the  work  for  a  few  minutes  at  the  end  of  half  an  hour  or 
an  houi\  This  rests  the  eye,  which  is  then  able  to  resume  the  employ- 
ment with  renewed  vigour  and  ease.  If  the  asthenopia  does  not  quite 
disappear  under  the  use  of  glasses,  we  must  examine  the  power  of  con- 
vergence, for  together  with  the  hypermetropia  there  may  exist  insuffi- 
ciency of  the  internal  recti  muscles,  and  the  asthenopia  be  partly  due 
to  this.  If  the  accommodation  has  been  greatly  fatigued  by  prolonged 
work  at  near  objects  without  the  aid  of  glasses,  or  if  there  is  spasm  of 
the  ciliary  muscle,  the  accommodation  should  be  placed  in  a  condition 
of  complete  rest,  by  being  paralysed  by  a  strong  solution  of  atropine ; 
and  this  paralysis  should  be  maintained  for  several  weeks. 

Bonders  has  shown  that  convergent  strabismus  very  frequently 
depends  upon  hypermetropia.  A  person  suffering  from  the  latter, 
is  always  obliged  to  accommodate  more  or  less,  in  order  to  see 
with  distinctness.  Even  at  a  distance,  he  must  already  accommo- 
date in  order  to  neutralize  the  hypermetropia,  and  the  nearer  the 
object  is  approximated,  the  more  will  this  tension  of  the  accom- 
modation increase.  There  exists,  however,  a  certain  relation  between 
the  accommodation  and  the  convergence  of  the  optic  axes,  for  with  an 
increase  of  the  latter  there  is  also  an  increase  in  the  power  of  accom- 
modation.    This  assertion  is  proved  by  the  fact,   that  if  we  place  a 


524  ANOMALIES   OF  REFRACTION   AND   ACCOMMODATION. 

prism  with  its  base  turned  outward  before  a  hypermetropic  eye,  the 
latter  will  squint  inwards,  in  order  to  avoid  diplopia  in  looking  at 
distant  objects,  and  this  convergence  will  enable  the  eye  to  accommo- 
date for  parallel  rays  (distant  objects)  ;  whereas,  with  parallel  optic 
axes,  it  before  required  convergent  rays,  i.e.,  the  rays  from  a  distant 
object  had  to  be  rendered  convergent  by  means  of  a  convex  glass,  in 
order  to  be  brought  to  a  focus  upon  the  retina.  Again,  if  we  place  a 
concave  glass  before  a  normal  eye,  we  change  it  into  a  hypermetropic 
one ;  parallel  rays  are  united  hehind  the  retina,  and  it  either  requires 
an  effort  of  accommodation  or  a  convex  glass  to  bring  them  to  a  focus 
on  the  retina.  If  the  concave  lens  is  but  of  slight  power,  an  increased 
effort  of  accommodation, — an  increase  in  the  convexity  of  the  crystal- 
line lens, — will  neutralize  the  efiect  of  the  concave  lens,  and  overcome 
this  artificial  hypermetropia.  But  if  the  concave  glass  is  too  strong  for 
this,  the  eye  often  overcomes  its  effect  by^  squinting  inwards,  and  thus 
considerably  increasing  its  power  of  accommodation.  Now  the  same 
thing  frequently  occurs  in  hypermetropia ;  for  the  eye  squints  inwards 
in  order  to  increase  its  power  of  accommodation.  This  has  been  called 
periodic  squinting.  In  the  beginning,  no  deviation  of  the  optic  axes  is 
observable  as  long  as  the  person  is  not  looking  sharply  at  anything ; 
but  as  soon  as  he  looks  intently  at  any  object,  near  or  distant,  conver- 
gent squint  shows  itself.  Sometimes,  this  only  occurs  when  the  patient 
is  looking  at  near  objects,  the  squint  disappearing  as  soon  as  he 
regards  distant  objects.  After  a  time  the  squint  becomes  permanent, 
particularly  in  those  persons  who  work  at  near  objects,  whether  in 
reading,  writing,  or  sewing.  We  meet  with  it  very  frequently  in 
children  about  the  third  or  fourth  year,  when  they  first  look  attentively 
at  things,  or  begin  to  use  their  eyes  for  any  length  of  time  for  near 
objects.  "When  this  tendency  to  squint  first  shows  itself,  it  may  be 
corrected  by  neutralizing  the  hypermetropia  by  means  of  convex 
glasses,  but  will  generally  require  an  operation. 

Moreover,  the  patient  should  always  be  warned  beforehand  that  after 
the  operation  of  strabismus,  it  may  be  necessary  to  wear  glasses  in 
order  to  prevent  the  recurrence  of  the  squint. 

The  cause  of  the  ap;parent  divergent  strabismus  which  is  often 
noticed  in  marked  cases  of  hypermetropia,  has  already  been  explained 
to  be  due  to  the  considerable  angle  formed  by  the  visual  line  and  optic 
axis  on  the  cornea  of  hypermetropic  eyes  ;  for  as  the  visual  line  in  the 
latter  lies  much  to  the  inner  side  of  the  optic  axis  on  the  cornea,  it  will 
be  at  once  evident  that  if  the  visual  lines  are  parallel  (fixed  upon  some 
distant  object)  the  optic  axes  will  diverge,  often  to  a  marked  degree. 
In  high  degrees  of  myopia  the  reverse  obtains,  for  as  the  visual  line 
then  often  lies  to  the  outer  side  of  the  optic  axis,  an  apparent  convergent 
squint  will  arise  when  the  visual  lines  are  parallel. 


ASTIGMATISM.  525 


7.— ASTIGMATISM. 

We  have  socu  tliat  the  anomalies  of  refraction  resolve  themselves 
into  two,  viz.,  myopia  and  hypermetropia.  But  the  state  of  refraction 
may  vary  in  the  different  meridians  of  the  same  eye;  thus,  it  may  be 
emmetropic  in  the  vertical  meridian,  but  myopic  or  hypermetropic  in 
the  horizontal,  or  vice  versa.  Or  differences  in  the  degree  and  even  in 
the  form  of  emmetropia  may  exist  in  the  various  meridians.  This  asym- 
metry has  been  termed  astigmatism  (a,  privative,  and  oTi^/fin,  a  point), 
which  signifies  that  rays  emanating  from  a  point  are  not  re-united  at  a 
point.  This  peculiar  defect*  was  first  observed  by  Thomas  Young 
(1793),  who  considered  it  due  to  some  inequality  in  the  structure  of 
the  lens,  whereas  Wharton  Jones  thought  its  seat  was  in  the  cornea. 
Donders  has  shown  that  it  is  of  frequent  occurrence,  and  that  many 
cases  of  congenital  amblyopia  are  due  to  it,  and  may  be  cured  by  proper 
cylindrical  glasses. 

But  even  in  the  normal  eye,  the  cornea  does  not  refract  equally  in 
all  its  meridians,  for  the  focal  distance  of  the  dioptric  system  is 
generally  shorter  in  the  vertical  meridian  than  in  the  horizontal.  On 
this  account,  fine  vertical  lines  can  be  seen  up  to  a  further  distance  than 
horizontal  lines,  but  the  latter  can  be  seen  closer  than  the  vertical  ones. 
For  this  experiment  horizontal  and  vertical  lines  may  be  drawn  upon  a 
page,  or  Von  Graefe's  wire  optometer  may  be  used. 

If  the  stripes  or  lines  are  arranged  crosswise,  we  are  unable  to  dis- 
tinguish both  the  horizontal  and  vertical  lines  with  equal  clearness  and 
distinctness  at  one  and  the  same  distance  ;  thus,  if  we  can  see  the  vertical 
line  clearly  and  sharply  defined,  we  must  approach  the  horizontal  line 
nearer  to  the  eye,  in  order  to  gain  an  equally  distinct  image  of  it,  and 
vice  versa.  These  facts  prove  that  the  vertical  meridian  has  a  shorter 
focal  distance  than  the  horizontal,  and  for  this  reason  horizontal  lines 
are  seen  distinctly  at  a  shorter  distance  than  vertical  ones.  For  as  the 
rays  which  are  refracted  in  the  vertical  meridian  are  united  in  a  point 
sooner  than  those  in  the  horizontal  plane,  these  latter  give  rise  to  circles 
of  difi"usion  upon  the  retina  in  the  fonn  of  small  horizontal  lines  which 
do  not  confuse  the  images  of  horizontal  lines,  but  interfere  with  those 
of  vertical  lines. 

As  it  is  of  much  consequence  in  the  study  of  astigmatism  that 
the  reader  should  thorouglily  understand  these  preliminary  facts,  I  give 
the  following  extract  and  explanatory  woodcuts  from  Donders'  work. 
After  speaking  .of  the  fact  that  a  vertical  stripe  can  be  seen  further  off 
and  a  horizontal  stripe  at  a  closer  distance  he  continues  : — "  These 

*  For  a  most  iutercsting  historical  account  of  this  subject,  see  Uoudcrs'  work, 
p.  53<J. 


520  ANOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

experiments  prove  that  the  points  of  the  refracting  meridians  are  not 
symmetrically  arranged  around  one  axis.  The  asymmetry  is  of  such  a 
nature  that  the  focal  distance  is  shorter  in  the  vertical  meridian  than 
in  the  horizontal.  In  order,  namely,  to  see  a  vertical  stripe  acutely, 
the  rays,  which  in  a  horizontal  plane  diverge  from  each  point  of  the  Une, 
must  be  brought  to  a  focus  upon  the  retina ;  it  is  not  necessary  that 
those  diverging  in  a  vertical  plane  should  also  previously  converge  into 
one  point,  as  the  diflfusion-images  still  existing  in  a  vertical  direction 
cover  one  another  on  the  vertical  stripe.  On  the  other  hand,  in  order 
to  see  a  horizontal  stripe  acutely,  it  is  necessary  only  that  the  rays  of 
light  diverging  in  a  vertical  plane  should  unite  in  one  point  upon  the 
retina.  Now  horizontal  lines  are  acutely  seen,  as  I  have  remarked,  at 
a  shorter  distance  than  vertical  ones,  consequently  rays  situated  in  a 
vertical  plane,  which  are  refracted  in  the  vertical  meridian  of  the  eye, 
are  more  speedily  brought  to  a  focus  than  those  of  equal  divergence 
situated  in  a  horizontal  plane  ;  and  the  vertical  meridian,  therefore,  has 
a  shorter  focal  distance  than  the  horizontal. 

"The  correctness  of  this  view  appears  further  from  the  form  of  the 
diffusion-images  of  a  point  of  light.  In  accurate  accommodation  the 
diffusion-spot  is  very  small,  and  nearly  round,  while  a  nearer  point 
appears  extended  in  breadth,  and  a  more  remote  one  seems  to  be  ex- 
tended in  height.  The  signification  of  this  phenomenon  must  be  clearly 
understood,  and  appears,  therefore,  to  demand  more  particular 
explanation. 

"  Let  us  suppose  the  total  deviation  of  light  in  the  eye  to  be  pro- 
duced by  a  single  convex  refracting  surface,  with  the  shortest  radius  of 
curvature  in  the  vertical,  and  the  longest  in  the  horizontal  meridian. 
These  two  are  then  the  principal  meridians.  Through  a  central  round 
opening  (Fig.  71,  v  v  li  li)  let  a  cone  of  rays,  proceeding  from  a  point 
situated  in  the  prolongation  of  the  axis  of  vision, 
fall  upon  this  surface ;  of  this  cone  let  us  con- 
sider only  the  rays  situated  in  the  vertical  plane 
V  V,  and  the  rays  situated  in  the  horizontal 
plane  h  h,  whereof  respectively  the  points  v  v  and 
h  h  are  the  most  external.  After  the  refraction, 
both  approach  the  visual  axis  (which  perpendi- 
cular to  the  plane  of  the  drawing  passes  through 
a),  V  V  does  so,  however,  more  rapidly  than  li  h. 
Before  union  they  therefore  lie  in  the  ellipse  A,  as  in  Fig.  72,  and 
where  v  v  meet  in  one  point  B,  h  h  have  not  yet  come  to  a  focus. 
Thereupon  we  now  find  in  succession  v  v  already  intersected,  h  h  ap- 
proached to  one  another,  G,  D,  E ;  further,  /(  h  united  in  one  point, 
and  V  V  after  intersection  more  widely  separated,  F ;  finally,  both  inter- 
sected, G.     The  focus  of  u  u  therefore  lies  most  anteriorly,  that  of  h  h 


ASTIGMATISM. 


527 


most  posteriorly  in  the  axis.  The  space  between  the  two  points,  where 
rays  of  different  meridians  intersect,  may  be  called  the  focal  interval 
(intervalle  fucale,  or  Brennstrecke  of  Sturm).     From  the  above  figures, 

Fig.  72. 


-ih  li 


h    h  i— |— )  li      li 


01i     1 1   l-Hh 


li  !- 


ih 


it  is  now  evident  what  successive  forms  the  section  of  the  cone  of 
light  will  exhibit.  In  the  middle  of  the  focal  interval  D,  it  will  be 
nearly  round,  and  anteriorly  through  oblate  ellipses,  C,  with  increasing 
eccentricity,  it  will  pass  into  a  horizontal  line  B  ;  posteriorly  through 
prolate  ellipses,  E,  it  Avill  come  to  form  a  vertical  line  F,  while  before 
the  focal  interval  a  larger  oblate  ellipse,  A,  and  behind  it  a  larger 
prolate  ellipse,  G,  wall  be  found." 

The  position  of  these  figures  with  regard  to  the  focal  interval  is 
shown  in  Fig.  73.  In  the  cone  of  light  emanating  from  L,  are  depicted 
the  rays  which  impinge  upon  the  vertical  meridian  V  V  and  upon  the 
horizontal  meridian  H  H.  The  former  are  united  in  o,  the  latter  in 
m,  so  that  o  m  is  the  focal  interval. 


Fig.  73. 


A    B  C  D     E 
After  SehirinLT. 


In  Fig.  73,  the  letters  A,  B,  C,  D,  E,  F,  and  G  correspond  to  the 
same  letters  in  Fig.  72.  The  rays  which  lie  in  the  plane  of  the  vertical 
m.eridian  V  V  (in  Fig.  73),  are  brought  to  a  focus  at  o,  where  the  rays 
which  lie  in  the  plane  of  the  horizontal  meridian  H,  H,  are  not  yet 
united,  but  form  the  horizontal  line  h  h  (the  anterior  focal  line).  The 
rays  H  H  are  united  further  back  at  m,  Avhere  the  vertical  rays  form 
the  vertical  line  v  v  (the  posterior  focal  line).  The  distance  between 
these  two  focal  lines  forms  the  focal  interval.  The  anterior  focal  line 
h  h,  corresponds  to  the  position  of  the  meridian  of  the  lowest  refractive 


528  ANOMALIES   OF  REFRACTION   AND   ACCOMMODATION. 

power,  whereas  the  posterior  focal  line  v  v,  to  that  of  the  meridian  ot 
highest  refraction.  Generally  the  astigmatic  patient  endeavours  un- 
consciously so  to  regulate  his  accommodation  that  the  middle  portion 
of  the  focal  interval  falls  upon  the  retina ;  in  this  way  only  a  small 
round  circle  of  diffusion  D  (Fig.  72),  is  formed,  and  the  object  is  more 
distinctly  seen  than  it  would  be  at  the  anterior  or  posterior  extremity  of 
the  focal  interval.  In  case  that  the  anterior  extremity  of  the  focal 
interval  (and  if  this  is  the  focus  of  the  vertical  meridian)  falls  upon 
the  retina,  a  cu'cular  flame  appears  as  a  horizontal  luminous  line.  The 
reverse  will  of  course  occur  if  the  posterior  extremity  of  the  focal 
line  (if  this  corresjDonds  to  the  focus  of  the  horizontal  meridian)  falls 
upon  the  retina,  for  then  the  flame  will  appear  as  a  vertical,  luminous 
line.  Hence,  horizontal  and  vertical  stripes  will  be  sharply  and  dis- 
tinctly seen  when  the  diffusion-images  of  all  the  points  of  the  stripe 
form  respectively  horizontal  and  vertical  lines,  which  cover  one  another 
in  the  stripe ;  and  this  will  be  the  case  when  the  beginning  and  the 
end  of  the  focal  interval  correspond  respectively  to  the  percipient 
surface  of  the  retina  (Bonders). 

Although  we  have  hitherto  assumed  that  the  principal  axes  of  curva- 
ture corresponded  with  the  vertical  and  horizontal  meridians,  it  must 
be  mentioned  that  they  may  deviate  considerably  from  these.  Also, 
that  instead  of  the  minimum  of  curvature  corresponding  with  the 
horizontal  meridian,  and  the  maximum  with  the  vertical,  the  reverse 
may  even  obtain,  and  the  maximum  curvature  coincide  with  the  hori- 
zontal meridian. 

The  aberration  which  is  due  to  a  difference  in  the  focal  distance  of 
the  two  principal  meridians,  is  called  regular  astigmatism,  and  depends 
uj)on  the  curvature  of  the  cornea.  Whereas  the  aberration  which  is 
due  to  a  difference  in  the  refraction  in  one  and  the  same  meridian,  is 
called  irregular  astigmatism,  and  is  generally  caused  by  a  peculiarity  in 
the  structure  of  the  crystalhne  lens,  and  cannot  be  corrected  by  cylin- 
drical lenses.  It  often  gives  rise  to  monocular  polyopia.  The  two 
forms  sometimes  co- exist.  The  degree  of  regular  astigmatism  met 
with  in  noi'mal  eyes  is  generally  too  slight  to  cause  any  impairment  of 
vision ;  but  when  it  is  more  considerable,  the  sight  is  indistinct.  This 
amblyopia  is  due  to  circles  of  diffusion  being  formed  upon  the  retina, 
which  cross  and  overlap  each  other.  The  greater  the  difference  in  the 
refraction  of  the  principal  meridians,  the  more  considerable  will  be  the 
circles  of  diffusion  and  consequent  indistinctness  of  vision.  If  the 
astigmatism  is  at  all  high  in  degree,  the  acuteness  of  vision  is  much 
impaired,  both  for  near  and  distant  objects.  If  the  eye  is  myopic  or 
hypermetropic,  we  find  that  we  cannot  with  any  spherical  lens  produce 
a  very  decided  improvement,  or  raise  the  acuteness  of  vision  to  the 
normal  standard. 


ASTIGMATISM.  529 

The  diagnosis  of  astigmatism  may  generally  be  made  without  much 
difficulty ;  but  it  is  necessary  to  follow  a  settled  line  of  examination, 
otherwise  the  beginner  will  fall  into  great  confusion,  and  waste  a  large 
amount  of  time.  Numerovis  modes  of  discovering  the  presence  of 
astigmatism,  and  of  estimating  its  degree  are  in  use ;  but  the  following 
are  the  simplest  and  most  practical. 

In  the  first  place,  we  must  carefully  examine  the  acuteness  of  vision, 
and  ascertain  which  number  of  Snellen's  types  the  patient  can  see  at  a 
distance  of  20'.  If  the  acuteness  of  vision  is  below  the  normal  standard 
(if  he  cannot  read  No.  xx),  we  must  try  whether  it  can  be  raised  to 
this  by  concave  or  convex  spherical  lenses.  If  we  fail  in  doing  so,  we 
must  suspect  the  presence  of  astigmatism,  and  next  proceed  to  deter- 
mine the  situation  of  the  two  principal  meridians  {i.e.,  the  maximum 
and  minimum  of  curvature).  This  may  be  done  by  directing  the  patient 
to  look  at  a  small,  distant  point  of  light  (varying  from  two  to  four 
millimetres  in  diameter,  and  seen  through  a  small  opening  in  a  large 
black  screen).  The  patient  should  be  placed  at  a  distance  of  fi'om  12  to 
16  feet,  and  directed  to  look  at  the  luminous  point.  The  latter  will  not 
appear  round  if  the  eye  is  astigmatic,  but  will  be  elongated  in  a 
certain  direction,  according  to  the  fact  whether  the  light  is  nearer  or 
further  off  than  the  point  for  which  the  eye  is  accommodated.  Thus, 
if  the  maximum  of  curvature  coincides  with  the  vertical  meridian,  the 
luminous  line  will  be  horizontal  if  the  eye  is  accommodated  for  a  further 
point,  and  vertical  if  it  is  adjusted  for  a  nearer  point.  Weak  concave 
and  convex  lenses  are  then  placed  alternately  before  the  eye  (the  latter 
being  thus  changed  into  a  myopic  or  hypermetropic  one),  and  the 
anterior  and  posterior  focal  line  brought  alternately  upon  the  retina. 
The  direction  of  this  line  will  depend  of  course  upon  the  direction  of 
the  principal  meridian. 

A  better  test  object  is,  however,  formed  by  a  series  of  straight  lines, 
which  cross  each  other  in  the  centre  of  a  circle.  For  this  purpose,  I 
have  found  Dr.  Green's*  test  objects  the  best,  and  use  them  in  pre- 
ference to  any  others.  He  employs  tliree  figures, 
which  can  be  arranged  in  such  a  manner  as  to  ^" 

ampUfy  and  check  the  results  obtained.  I  have, 
however,  found  that  one  of  the  diagrams  (Fig. 
74)  is  sufficient.  It  consists  of  a  circle,  tra- 
versed by  a  set  of  twelve  triple  lines,  corre- 
sponding to  the  figures  on  a  watch  dial ;  the 
figures  being  placed  at  the  extremity  of  the 
sets  of  lines,  as  in  Javal's  optometer  (Fig.  75). 
Each  line  is  equal  in  thickness  to   the    lines 

*  Vide  Dr.  Green's  paper  on  "  The  Detection  and  Measurement  of  Astigma- 
tism," in  the  American  Joiu-nal  of  Medical  Sciences,  January,  1867. 

2   M 


530  ANOMALIES   OF  REFRACTION   AND   ACCOMMODATION." 

employed  by  Snellen  in  the  construction  of  No.  xx  of  his  test  types, 
and  is  designed  to  be  distinctly  seen  at  a  distance  of  about  20'.  The 
circle  is  about  12^"  in  diameter. 

This  test  circle  is  to  be  placed  at  a  distance  of  20',  and  if  the 
patient  can  see  all  the  lines  distinctly  and  sharply  defined  (any  existing 
myopia  or  hypermetropia  being  corrected  by  suitable  spherical  lenses), 
he  is  not  astigmatic.  But  if  only  the  line  in  one  meridian  appears 
clear  and  sharply  defined,  whilst  the  others  are  indistinct,  the  presence 
of  astigmatism  is  proved,  and  the  direction  of  the  distinct  line  cor- 
responds to  the  meridian  of  the  highest  refraction.  If  we  now  wish  to 
discover  the  degree  and  nature  of  the  astigmatism,  and  are  only  sup- 
plied with  spherical  lenses,  we  try  the  weakest  concave  or  the  strongest 
convex  lens  which,  placed  in  a  stenopaic  apparatus,*  enables  the  patient 
to  see  all  the  radiating  lines  with  equal  distinctness.  If  a  concave  lens 
is  required,  it  is  a  case  of  myopic  astigmatism,  whereas,  it  is  hyperme- 
tropic, if  a  convex  lens  is  requii-ed. 

If  we  possess  a  trial  case  of  cylindrical  lenses,  the  weakest  concave 
or  strongest  convex  cylindrical  glass  should  be  found  which  renders  all 
the  radiating  lines  quite  distmct  and  clearly  defined.  When  we 
have  found  the  lens  which  corrects  the  astigmatism,  the  patient's  sight 
should  next  be  tried  with  Snellen's  test  types,  in  order  that  we  may 
accurately  ascertain  the  degree  of  improvement  of  sight  produced  by 
it.  In  cases  of  hypermetropia,  the  effort  of  accommodation  often 
conceals  a  considerable  portion  of  the  astigmatism,  and  may  thus 
greatly  mislead  us  as  to  its  actual  degree.  The  examination  is  there- 
fore greatly  facilitated,  if  the  accommodation  is  first  paralysed  by  atro- 
pine. 

In  the  above  modes  of  examination  each  eye  is  to  be  tried  separately. 

Javal  has  devised  the  following  ingenious  instrument  for  the  rapid 
determination  and  correction  of  astigmatism. f  It  is  in  the  form  of 
a  stereoscope  mounted  upon  a  stand,  and  is  supplied  with  convex 
spherical  lenses  of  about  5"  focus.  In  high  degrees  of  hypermetropia 
a  lens  of  3"  should  be  employed,  whereas,  in  high  degrees  of  myopia 
we  may  omit  the  convex  lenses,  or  substitute  concave  ones.  Two  circles 
are  drawn  side  by  side  upon  a  piece  of  card  board,  just  as  in  a  stereo- 
scopic plate,  being  at  such  a  distance  from  each  other,  that  the  centre 
of  each  circle  corresponds  to  the  distance  between  the  two  eyes.     In 

*  The  stenopaic  apparatus  employed  foi'  this  purpose,  consists  of  a  small  cylinder 
open  at  one  end,  so  as  to  fit  closely  to  tlie  eye,  tlie  other  end  being  furnished  with  a 
small  slit,  which  can  be  readily  narrowed  and  widened.  The  effect  of  tliis  slit  (which 
should  be  set  to  a  width  of  about  1|  or  2  millimeti'cs),  is  of  course  to  admit  only 
rays  in  a  certain  direction,  excluding  all  the  othci's.  The  box  of  the  cylinder  should 
be  made  to  unscrew,  in  order  that  splicrical  lenses  may  be  placed  in  it. 

t  "  Kl.  Monatsbl.,"  1865,  336.  This  optometer  of  Javal's  is  made  by  Nachet, 
17,  Rue  St.  Severin,  Paris. 


ASTIGMATISM. 


531 


the  one  figure  (Fig.  75)  are  drawn  a  series  of  radiating  lines,  and  at 
their  extremity  ai-e  placed  the  figures  I  to  XII,  arranged  like  the  figures 
on  a  watch  dial.  If  the  visual  lines  are  parallel,  the  two  circles  are 
fused  into  one  image,  in  the  centre  of  which  lie  the  radiating  stripes. 


Fig.  75. 


and  at  the  circumference  the  figures.  On  account  of  the  parallelism 
of  the  eyes,  the  latter  are  accommodated  for  their  far  point.  By  means 
of  a  screw,  the  circles  are  now  removed  further  and  further  from  the 
eyes,  until  all  the  radiating  lines,  except  one,  become  indistinct.  The 
direction  of  this  one  is  easily  identified  by  the  figures,  and  its  direction 
corresponds  to  the  diameter  of  the  highest  refraction.  Behind  the 
ocular  lens  of  the  one  eye  is  arranged,  upon  a  pivot,  a  series  of  concave 
cylindrical  lenses,  so  that  they  can  be  rapidly  rotated  in  front  of  the  eye, 
until  the  lens  is  found  which  corrects  the  astigmatism  and  indicates  its 
degree.  These  lenses  are  arranged  in  such  a  manner,  that  they  can  be 
used  singly  or  together,  thus  allowing  of  most  varied  combinations.  After 
the  degfree  of  astigmatism  has  been  determined,  the  state  of  the  refrac- 
tion  of  the  eye  must  be  ascertained,  and  the  same  apparatus  may  be 
used  for  this  purpose.  After  the  examination  of  the  one  eye  has  been 
finished,  that  of  the  other  should  be  proceeded  with,  the  series  of 
cylindrical  lenses  being  turned  over  to  the  other  side.  The  principal 
objection  to  this  instrument  is,  that  on  account  of  the  patient  being 
conscious  of  the  close  proximity  of  the  object,  he  does  not  relax  his 
accommodation  completely,  and  is  hence  not  in  reality  accommodated 
for  his  far  point,  and  we  may  therefore  fall  into  error  as  to  the  degree  of 
his  astigmatism.  This  error  is  to  a  great  extent  avoided  if  we  test  him 
with  the  radiating  lines  at  a  distance,  and  completely  so,  if  in  a  case  of 
hypermetropia  the  accommodation  is  paralysed. 

Donders  has  distinguished  three  forms  of  astigmatism,  viz. :  I. 
Simple  astigmatism  ;  II.  Comjiouud  astigmatism ;  III.  Mixed  astig- 
matism. 

2  M  2 


532    ANOMALIES  OF  REFRACTION  AND  ACCOMMODATION. 

I.  Simple  Astigmatism.— The  state  of  refraction  of  the  one  prin- 
cipal meridian  is  emmetropic,  whereas,  that  of  the  other  is  either  myopic 
or  hypermetropic.  If  we,  in  such  a  case,  turn  the  slit  of  the  stenopaic 
apparatus  in  the  dii-ection  of  the  normal  meridian,  the  acnteness  of 
vision  will  be  perfect,  whereas,  a  certain  concave  or  convex  spherical 
lens  will  be  required  if  the  slit  is  turned  in  the  dii-ection  of  the  other 
meridian. 

Simple  astigmatism  is  divided  into  : — 1.  Simple  myopic  astigmatism 
(Am),  in  which  myopia  exists  in  the  one  principal  meridian,  and  em- 
metropia  in  the  other.  2.  Simple  Hypermetropic  Astigmatism  (Ah). 
— In  this  there  is  hypei-metropia  in  the  one  principal  meridian,  and 
emmetropia  in  the  other. 

II.  Compound  Astigmatism. — In  this  form,  myopia  or  hyperme- 
tropia  exists  in  both  principal  meridians,  but  it  varies  in  degree.  If 
the  stenopaic  slit  be  used  in  such  cases,  it  will  be  found  that  a  different 
concave  or  convex  lens  will  be  required  in  each  of  the  principal  meri- 
dians, in  order  to  render  the  acuteness  of  vision  normal. 

We  must  here  also  distinguish  two  forms: — 1.  Compound  Myopic 
Astigmatism  (M  +  Am). — Myopia  exists  in  both  principal  meridians. 
2.  Compound  Hypermetropic  Astigmatism  (H  +  Ah). — Hypermetropia 
exists  in  both  principal  meridians. 

III.  Mixed  Astigmatism. — This  is  a  rare  form,  in  which  the  one 
principal  meridian  is  myopic,  the  other  hypermetropic.  We  must  here 
also  distinguish: — 1.  Mixed  astigmatism,    with    predominant    myopia 

(Amh).      2.  Mixed    astigmatism,    with    predominant    hypermetropia 

(Ahm). 

Knapp  and  Schweigger  have  pointed  out  that  the  ophthalmoscope 
also  furnishes  us  with  a  valuable  and  easy  diagnostic  symptom  of 
regular  astigmatism.  On  examining  in  the  direct  method  an  eye 
affected  with  astigmatism,  it  will  be  found  that  the  optic  disc,  instead 
of  being  round,  appears  elongated  in  one  direction,  and  that  the  latter 
corresponds  exactly  to  the  meridian  of  greatest  curvature.  For  as  the 
focal  distance  is  shorter  in  this  meridian  than  in  the  other,  the  image 
must  also  be  more  magnified  in  this  direction.  If  we  now  examine  the 
same  eye  in  the  inverted  image,  the  optic  disc  will  appear  elongated  in 
the  opposite  direction ;  thus,  if  in  the  erect  image  the  disc  appears  oval 
in  the  vertical  direction,  in  the  inverted,  it  will  appear  oval  in  the  hori- 
zontal direction,  and  this  at  once  proves  the  existence  of  regular  astig- 
matism, and  shows  also  that  the  vertical  meridian  is  of  greater  curvature, 
and,  consequently,  has  a  less  focal  distance,  than  the  horizontal.  The 
comparative  examination  in  the  erect  and  inverted  image  therefore 
furnishes  us  with  a  most  valuable  aid  to  diagnosis,  which  will  often 
spare  us  the  necessity  of  a  long  and  intricate  subjective  examination. 

In  examining,  in  the  erect  image,  an  eye  affected  with  hypermetropic 


ASTIGMATISM.  533 

astigmatism,  it  will  also  be  found  that  in  order  to  see  with  equal  distinct- 
ness the  vessels  running  in  different  directions,  the  state  of  accommoda- 
tion of  the  observer's  eye  has  to  undergo  a  change. 

Mr.  Bowman  "  has  been  sometimes  led  to  the  discovery  of  regular 
astigmatism  of  the  cornea,  and  the  direction  of  the  chief  meridians  by 
using  the  mirror  of  the  ophthalmoscope  much  in  the  same  way  as  for 
slight  degrees  of  conical  cornea.  The  observation  is  more  easy  if  the 
optic  disc  is  in  the  line  of  sight  and  the  pupil  large.  The  mirror  is  to 
be  held  at  two  feet  distance,  and  its  inclination  rapidly  varied,  so  as  to 
throw  the  light  on  the  eye  at  small  angles  to  the  perpendicular,  and 
from  opposite  sides  in  succession,  in  successive  meridians.  The  area  of 
the  pupil  then  exhibits  a  somewhat  linear  shadow  in  some  meridians 
rather  than  in  others."  * 

Astigmatism  is  generally  congenital  and  often  hereditary ;  it  may, 
however,  also  be  acquired.  The  congenital  astigmatism  is  mostly 
regular  and  dependent  upon  asymmetry  of  the  cornea.  In  the  majority 
of  cases  it  is  present  in  both  eyes,  although  perhaps  in  varying  degree. 
Donders  has  found  that  abnormal  astigmatism  occurs  far  more  fre- 
quently in  hypermetropic  eyes  than  others  ;  indeed,  he  even  thinks  that 
out  of  six  hypermetropic  eyes  one  suffers  from  abnormal  astigmatism. 
The  amblyopia  which  often  exists  in  hypermetropia,  and  which  cannot 
be  remedied  by  spherical  convex  lenses,  is  mostly  due  to  astigmatism. 
We  often  find  that  persons  unconsciously  correct  a  certain  amount  of 
astigmatism  by  holding  their  head  on  one  side,  and  thus  looking  slant- 
ingly through  their  spectacles. 

Acquired  astigmatism  is  mostly  caused  by  inflammatory  changes  in 
the  cornea,  which  lead  to  consecutive  flattening  of  the  cornea,  and 
leave  behind  them  opacities  and  cicatrices  ;  it  may  also  be  caused  by 
irregularity  in  the  apposition  of  the  edges  of  the  incision  after  the 
operation  of  extraction  of  cataract.  We  occasionally  find  that  if 
iridectomy,  or  iiidodesis,  is  performed  in  cases  of  opacity  of  the  cornea, 
a  considerable  degree  of  amblyopia  persists  after  the  operation,  although 
the  pupil  is  now  brought  opposite  to  a  transparent  portion  of  the  cornea. 
On  examination,  we  then  find  that  in  many  of  these  cases  this  weakness 
of  sight  is  due  to  astigmatism,  and  that  vision  is  greatly  improved  by 
a  cylindrical  lens.  Acquired  astigmatism  may  also  be  caused  by  dislo- 
cation of  the  crystalline  lens,  more  particularly  if  it  is  obliquely  dis- 
placed in  the  area  of  the  pupil. 

The  best  examples  of  pure  regular  astigmatism  are  furnished  by 
successful  cataract  operations,  for  then  any  irregular  astigmatism  wliich 
may  have  been  caused  by  the  lens  will,  of  course,  have  bean  removed. 

The  disturbance  of  vision  produced  by  even  a  slight  degree  of  astig- 
matism is  often  very  great  and  annoying,  as  the  form  and  shape  of 

*  Donders,  p.  4dO. 


534  AXOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

minute  objects  (sucli  as  small  letters)  are  so  changed,  that  they  cannot  be 
seen  with  distinctness,  but  look  blurred  and  confused.  This  is  due  to  the 
fact  that  certain  portions  of  a  letter  are  yet  quite  distinct,  whilst  others 
are  faint  or  unapparent.  Thus  the  vertical  lines  of  the  letter  H  may 
appear  quite  dark  and  clear,  whilst  the  horizontal  connecting  line  is 
almost  invisible.  This  also  gives  a  peculiar  tremulousness  and  un- 
certainty to  the  outline  of  the  object.  On  account  of  the  co-existence  of 
irregular  astigmatism,  the  patient  may  also  be  affected^  with  monocular 
diplopia  or  polyopia. 

Regular  astigmatism  may  be  remedied  by  the  use  of  cylindrical 
lenses,  which  enable  us  to  correct  the  anomaly  of  refraction  in  each  of 
the  principal  meridians. 

A  cylindrical  lens  is  the  segment  of  a  cylinder,  and  refracts  those 
rays  of  light  the  strongest  which  strike  it  in  a  plane  at  right  angles  to 
the  axis  of  cylindrical  curvature ;  whereas  the  rays  which  pass  through 
its  axis  suffer  no  deviation  at  all.  In  this,  therefore,  the  cyhndrical 
lens  diflFers  from  the  spherical,  which  refracts  the  rays  in  all  planes  of 
the  segment. 

Now,  if  in  a  case  of  simple  astigmatism  the  one  principal  meridian 
is  normal,  so  that  rays  passing  through  it  are  united  exactly  upon  the 
retina,  and  the  other  principal  meridian  is  myopic  or  hypermetropic, 
and  the  rays  passing  through  it  are  brought  to  a  focus  before  or  behind 
the  retina,  we  should  correct  this  anomaly  of  refraction  by  means  of  a 
cyhndrical  lens  whose  axis  corresponds  to  the  normal  meridian.  The 
effect  of  this  would  be  that  the  rays  which  pass  through  its  axis  would 
undergo  no  refraction,  whereas,  those  that  pass  in  a  plane  at  right 
angles  to  the  axis  would  undergo  the  necessary  refraction,  and  thus 
neutralize  the  anomaly  which  obtains  in  this  meridian. 

A  convex  cylindrical  lens  should  be  placed  in  such  a  direction  that 
its  axis  lies  in  the  plane  of  the  highest  refracting  meridian,  in  order  that 
it  may  give  to  the  rays  which  undergo  the  smallest  degree  of  deflection, 
such  an  increased  amount  of  convergence  as  if  they  passed  thi'ough  the 
meridian  of  the  greatest  refraction. 

The  reverse  obtains  in  the  case  of  concave  cylindrical  lenses,  for 
here  the  axis  must  correspond  to  the  meridian  of  least  refraction,  so 
that  the  focal  length  of  the  meridian  of  greatest  curvature  may  be  in- 
creased, and  made  equal  to  that  of  the  meridian  of  least  refraction.  A 
glance  at  Fig.  73,  p.  527,  will  readily  explain  this. 

I  will  now  illustrate  the  choice  of  cylindrical  lenses  by  some 
examples. 

I.  Simple  Astigmatism. — The  state  of  refraction  of  the  one  principal 
meridian  is  emmetropic,  whereas,  that  of  the  other  is  either  myopic  or 
h}7)ermetropic. 

1.  Simple  Myopic  Astigmatism  (Am). — Let  us  suppose  that  there  is 


ASTIGMATISM.  535 

emmetropia  in  the  principal  horizontal  meridian  (the  far  point  lying  at 
an  infinite  distance,  i.e.,  R  =    oo),  biit  that   in  the  principal  vertical 

meridian  there  is  myopia  =  -,  then  Am  =   -  —  _   =  _. 

•^  -^  8  8       a^        8 

In  order  to  correct  this,  a  concave  cylindrical  lens  of  8  inches  focns 
will  be  required,  its  axis  corresponding  to  the  horizontal  meridian,  so 
that  the  rays  of  light  may  here  pass  without  undergoing  any  refraction, 
and  only  those  which  pass  at  a  right  angle  to  the  axis  (vertically)  be 
refracted,  so  as  to  neutralize  the  myopia  which  exists  in  the  principal 
vertical  meridian.  To  be  quite  accm^ate  the  lens  should  be  slightly 
stronger  (7^  inches  focus),  for  ^  an  inch  should  be  deducted  from  the 
strength  of  the  concave  lens,  on  account  of  the  distance  of  the  latter 
from  the  nodal  point.  In  hypermetropia,  on  the  other  hand,  this  dis- 
tance of  about  ^  an  inch  must  be  added  to  the  number  of  the  convex 
lens.  In  slight  degrees  of  myopia  or  hypermetropia  (below  Jg-  or  ■^) 
we  may,  however,  omit  this  distance  in  the  calculation. 

2.  Simple  Hypermetropic  Astigmatism  (Ah). — In  the  horizontal 
meridian  let  there  be  hypermeti'opia  =  J^,  in  the  vertical  emmetropia, 

then  Ah   =  —   —  —   =  —  and  the  patient  will  require  a  convex  cvlin- 

drical  lens  of  10  inches  focus  with  its  axis  placed  vertically. 

II.  Compound  Astigmatism. — In  this  form,  it  will  be  remembered, 
myopia  or  hypermetropia  exists  in  both  the  principal  meridians,  but  it 
varies  in  degree. 

It  will  be  found  very  much  to  facilitate  the  understanding  of  these 
cases  of  compound  astigmatism,  if  we  consider  the  eye  to  be  affected 
with  simple  myopia  or  hypermetropia,  but  that  there  exists  besides,  a 
maximum  degree  of  this  anomaly  of  refraction  in  one  of  the  principal 
meridians.  We  have,  therefore,  a  certain  degree  of  myopia  or  hyper- 
metropia common  to  the  whole  eye,  besides  a  certain,  special  degree  in 
one  of  the  principal  meridians. 

1.  Compound  Myopic  Astiymatism  (M  +  Am). — Myopia  exists  in 
both  meridians,  but  to  a  higher  degree  in  the  one  than  in  the  other. 

In  the  principal  vertical  meridian  let  M  =  -Jg . 

In  the  principal  horizontal  meridian  let  M   =   -gL.,  we  then  have 

myopia   =^   —     and    Am   =    _    —   —    ^    __  to  be  written  as  M  = 
^   ^  30  15         30         30 

1  -f  Am  1. 

30  30 

In  such  a  case,  a  spherico- cylindrical  lens  is  required,  the  one  surface 
of  which  has  a  spherical,  the  other  a  cylindrical  curvature,  and  its  action 
is  that  of  a  piano-cylindrical  lens  combined  with  a  plano-sjiherical  lens, 
and  it  may  be  expressed  by  the  formula  for  each  of  the  refracting 
surfaces,  united  by  a  sign  of  combination. 


536  ANOMALIES   OF   REFRACTION  AND   ACCOMMODATION. 

The  case  which  we  have  supposed  would  therefore  be  corrected  by 

30     ^       30 

For  the  spherical  and  cylindrical  surface  would  require  to  have  a 
negative  focal  distance  of  30",  and  the  axis  of  the  cylindrical  surface 
would  have  to  be  placed  horizontally. 

2.  Compound  hypermetropic  astigmatism  (H  +  Ah).  Hyperme- 
tropia  exists  in  both  principal  meridians,  but  more  in  the  one  than  in 
the  other. 

In  the  vertical  raeridian  let  H  =  -^.     In  the  horizontal  meridian 

let  H   =:  —      We  have  then  H  =  — ,  and  moreover  Ah  = —  

12  18  12        18 

=  —   and  we  write  H  —  +  Ah  —    Hence  a  positive  spherico-cylind- 
36  18  36  t  f  J 

rical  lens  will  be  required,  and  it  will  be  corrected  by s  '~^  c. 

18      ^  36 
The  axis  of  the  cylindrical  surface  being  placed  vertically. 

III.  Mixed  astigmatism.  In  this  form,  in  which  myopia  exists  in 
the  one  principal  meridian,  and  hypermetropia  in  the  other,  we  must 
make  use  of  bi-cylindi"ical  glasses.  These  consist  of  two  cylindrical 
surfaces  of  curvature,  the  axes  of  which  are  perpendicular  to  one 
another ;  the  one  surface  is  concave,  the  other  convex.  In  consequence 
of  this,  the  effect  of  such  lenses  is  to  render  parallel  incident  rays 
divergent  in  the  plane  of  one  axis,  and  convergent  in  that  of  the  other. 
The  axis  of  the  concave  surface  must  be  placed  in  the  direction  of  the 
hypermetropic  meridian,  and  the  axis  of  the  convex  surface  in  the 
direction  of  the  myopic  meridian.  Their  action  may  be  expressed  by 
the  formula  for  each  of  the  two  planes,  united  by  a  sign  of  a  right 
angle  j". 

1.  Mixed  astigmatism,  with  predominant  myopia  (Amh). 

In  the  vertical  meridian  let  M  =  y\-     ^^^  ^^^  horizontal  meridian 

let  H  =  —     Therefore  Amh  =  M  —  +  H-—  =  -     and  is  corrected 
20  10  20        6|, 

by  —  c         —  —  c. 

•^  20      I  10 

The  axis  of  the  convex  surface  to  be  placed  vertically,  that  of  the 
concave  horizontally. 

2.  Mixed  astigmatism,  with  predominant  hypermetropia  (Ahm). 
In  the  vertical  meridian  let  M  =  yg^.     In  the  horizontal  meridian 

let  H  =  —      Therefore  Ahm  =11  +  M  —  =  —  and  is  corrected 

12  12  18        7i, 

by  —  c         —  —  c. 

12  18 

The  axis  of  the  convex  surface  to  be  placed  vertically,  that  of  the 
concave  surface  horizontally. 


ASTIGMATIS-M.  537 

These  examples  illustrate  the  method  to  be  adopted  in  finding 
glasses  to  correct  the  astigmatism  and  the  ametropia.  But  in  many 
cases  it  is  not  advisable  completely  to  neutralize  the  anomaly  of  refrac- 
tion, both  on  account  of  the  difference  in  the  size  of  the  retinal  images 
which  will  occui-  if  the  lenses  are  strong,  and  also  on  account  of  the 
disturbance  in  the  combined  action  of  the  ciliary  muscle  and  the 
internal  recti  muscles.  It  is  often  desirable  that  the  astigmatism 
should  be  wholly  corrected,  but  that  only  a  certain  portion  of  the 
myopia  or  hypermetropia  should  be  neutralized. 

After  the  operation  of  extraction  of  cataract,  the  sight  is  often 
materially  improved  by  cylindrical  lenses,  even  although  before  the 
opacity  of  the  lens,  the  sight  had  been  perfectly  normal.  Such  cases 
can  only  be  explained  on  the  supposition,  that  a  certain  degree  of 
corneal  astigmatism  had  been  neutrahzed  (compensated  for)  by  some 
lenticular  astigmatism,  so  that  when  the  lens  is  absent,  the  ill-effects 
from  the  cornenl  astigmatism  make  themselves  felt.  This  condition 
must  of  course  be  distinguished  from  the  acquired  astigmatism  due  to 
a  faulty  cicatrization  of  the  section.  In  all  cases  of  extraction,  in 
•which  the  sight  is  not  as  good  as  might  be  expected  from  the  general 
appearance  of  the  eye,  the  presence  of  astigmatism  should  be  looked 
for,  and  the  effect  of  cylindrical  lenses  tried. 

It  is  of  great  consequence,  that  the  axes  of  the  surfaces  of  curvature 
of  the  cylindrical  glasses  should  be  situated  in  the  principal  meridians 
of  the  eye,  for  even  a  very  slight  deviation  will  give  rise  to  considerable 
indistinctness  of  vision.  In  order  to  insure  the  exact  adaptation  of  the 
glasses  to  the  eye,  the  lenses  should  be  set  in  round  frames,  which 
permit  of  their  being  readily  rotated  in  any  direction.  When  the 
proper  position  of  the  axis  is  found,  the  screw  should  be  tightened,  and 
the  lens  thus  firmly  fixed  in  the  desired  position.  The  clumsy  and 
awkward  appearance  of  the  circular  frames  may  be  greatly  diminished 
by  making  them  of  a  smaller  diameter,  or  by  having  the  glasses  ground 
down  into  oval  ones,  and  then  reset  into  oval  frames.  But  this  requires 
great  exactitude  and  nicety. 

Irregular  astigmatism  depends  sometimes  upon  irregularities  in  the 
curvature  of  the  cornea,  such  as  occur  from  thinning  of  the  cornea 
after  comeitis,  in  conical  cornea,  and  a  faulty  union  of  the  section  in 
extraction  of  cataract.  Irregularities  in  the  structure  of  the  lens,  or  dis- 
placement of  the  latter,  so  that  its  edge  lies  partially  in  the  area  of  the 
pupil,  may  also  give  rise  to  this  form  of  astigmatism.  On  account  of 
these  irregularities  in  the  cornea  or  lens,  the  refraction  of  luminous 
rays  is  much  distorted,  for  not  only  do  the  rays  in  a  certain  diameter 
undergo  irregular  refraction,  but  even  perhaps  individual  rays  in  the 
same  diameter.  The  retina,  therefore,  receives  a  very  confused  and 
blurred  imao-e,  and  hence  there  is  always  a  considerable  impairment  of 


538  ANOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

vision,  the  object  looking  crooked  and  distorted.  Not  unfrequently 
there  is  marked  monocular  diplopia  or  polyopia.  Whilst  this  irregular 
astigmatism  cannot  be  corrected  by  cylindrical  glasses,  it  is  often  sus- 
ceptible of  improvement  by  stenopaic  spectacles,  which,  by  excluding  a 
large  portion  of  the  irregularly  refracted  rays,  render  the  image  less 
distorted  and  confused. 


8.— APHAKIA  (ABSENCE  OF  THE  CRYSTALLINE  LENS). 

This  condition  may  be  due  to  an  operation  for  cataract  {e.g.,  ex- 
traction, division,  or  reclination),  to  absorption  of  the  lens  after  trau- 
matic cataract,  or  dislocation  of  the  lens  into  the  vitreous  humour,  etc. 
The  state  of  refraction  is  of  course  greatly  altered  by  absence  of  the 
lens.  Thus,  an  emmetropic  eye  becomes  strongly  hypermetropic ;  a 
hypermetropic  eye  still  more  so;  whereas,  a  myopic  eye  will  become  less 
short-sighted,  or,  if  the  degree  of  myopia  was  very  great,  it  may  even 
become  emmetropic.  The  power  of  accommodation  is  completely  absent 
in  aphakia.  This  has  been  now  incontrovertibly  proved  by  Bonders' 
numerous  and  most  exact  experiments. 

The  acuteness  of  vision  even  after  the  most  successful  operations  for 
cataract,  and  with  the  aid  of  the  most  suitable  glasses,  does  not  usually 
reach  the  normal  standard.  In  old  persons,  this  is  frequently  due  to  cer- 
tain senile  changes  which  take  place  in  all  eyes,  and  often  considerably 
deterioi-ate  the  sight.  Another  not  unfrequent  cause  is  to  be  found  in  the 
presence  of  secondary  cataract,  or  even  in  the  wrinkling  of  the  trans- 
parent caps  ale,  which  may  produce  considerable  distortion  and  con- 
fusion of  the  retinal  image. 

Patients  who  have  been  operated  upon  for  cataract,  require  very 
strong  convex  glasses  to  neutralize  the  acquired  hypermetropia.  The 
strength  of  these  glasses  will  vary  according  to  the  degree  of  the 
hypermetropia,  i.e.,  the  length  of  the  optic  axis;  for  the  shorter  the 
latter  is,  the  stronger  will  the  lens  require  to  be.  Two  sets  of  glasses 
will  be  wanted,  one  for  distant  objects,  and  one  for  reading,  sewing,  etc. 
For  the  former  purpose,  the  number  generally  ranges  from  4"  to  5"  focus, 
for  the  latter  from  2"  to  2^"  focus.  But  as  this  varies  considerably, 
different  numbers  must  be  tried  until  the  best  is  foujid,  and  it  must 
be  remembered  that  in  these  lenses  of  high  power,  a  slight  difference 
may  exert  a  very  considerable  effect  upon  the  sight.  In  order  to  remedy 
the  great  spherical  and  chromatic  aberration  of  light,  which  is  jjroduced 
in  these  lenses  from  the  difference  in  their  thickness  at  the  centre  and 
at  the  periphery,  such  spectacles  are  generally  set  in  a  broad  horn  or 
tortoise-shell  frame,  which  leaves  only  the  more  central  portion  of  the 
glass  exposed. 


\ 


i 


PARALYSIS,   ETC.,   OF   THE   CILIARY   JIUSCLE.  539 


9.— PARALYSIS,  SPASM,  AND  ATONY  OF  THE  CILIARY 

MUSCLE. 

Diminution  or  loss  of  accommodation  from  paralysis  or  atony  of  tlio 
ciliary  muscle  is  occasionally  met  with  after  severe  illnesses,  the  whole 
muscular  system  being  greatly  debilitated.  In  such  cases,  it  is  not 
unfrequently  mistaken  for  amblyopia  dependent  upon  general  debility. 
It  is  also  often  met  with  after  diphtheria,  and  appears  to  depend  less 
upon  general  constitutional  weakness,  than  upon  some  special  and 
peculiar  cause,  the  exact  nature  of  which  is  yet  undetermined. 

The  symptoms  of  paralysis  of  the  accommodation  are  very  marked 
in  emmetropic  eyes.  The  patients  find  that  they  cannot  accurately 
distinguish  near  objects,  so  that  they  are  quite  unable  to  read,  write,  or 
sew ;  but  at  a  distance  they  can  see  distinctly.  The  far  point  has 
undergone  no  change  of  position,  but  the  near  point  has  receded  further 
from  the  eye.  If  we  test  the  sight  with  a  convex  lens  of  6"  focus,  we 
find  perhaps  that  the  near  point  has  receded  to  5"  or  5^"  from  the  eye, 
and  that  the  far  point  lies  at  6"  (the  focal  distance  of  the  lens),  hence 
that  the  power  of  accommodation  is  almost  entirely  lost.  The  position 
of  the  near  point  will  of  course  vary  with  the  degi'ee  of  paralysis  ;  if  this 
is  but  sHght  (paresis),  the  near  point  may  be  but  little  removed  from 
the  eye,  and  the  disturbance  of  vision  but  inconsiderable.  If  there  is 
complete  paralysis,  the  patients  cannot  generally  distinguish  any  print 
smaller  than  No.  14  or  16  of  Jiiger,  but  can  easily  read  the  finest  type 
with  strong  convex  lenses.  The  sight  is  much  less  affected  in  short- 
sighted persons,  for  if  the  myopia  =  -^  or  ^-j,  they  are  still  able 
to  read  at  their  far  point  (12"  or  14"),  as  only  the  near  point  under- 
goes a  change,  and  the  far  point  lies  sufficiently  close  to  the  eye 
to  permit  of  small  objects  being  seen  distinctly.  In  hypermetropic 
patients  it  is,  however,  quite  different,  for  in  them  both  the  near  and 
distant  sight  is  impaired,  just  as  after  the  instillation  of  atropine.  In 
incomplete  paralysis,  the  symptoms  often  resemble  those  of  asthenopia, 
and  the  true  nature  of  the  affection  may  be  easily  overlooked,  if  the 
range  of  the  accommodation  is  not  examined.  Together  with  the 
paralysis  of  the  accommodation,  there  is  almost  always  paralysis  of  the 
constrictor  pupillae,  and  consequent  dilatation  of  the  pupil,  as  both 
muscles  are  supplied  by  the  third  nerve ;  and  frequently  other  muscles 
of  the  eye,  supplied  by  this  nerve,  are  also  affected.  In  trying  the 
sight,  attention  should  be  paid  to  this  dilatation  of  the  pupil,  and  the 
consequent  presence  of  circles  of  diffusion  upon  the  retina,  and  the 
patient  should  be  directed  to  read  through  a  small  stenopaic  opening. 

The  treatment  of  cases  of  paralysis  of  the  ciHary  muscle  must 
depend  upon  the  cause.     If  the  patient  has  been   suffering  from  diph- 


540    ANOMALIES  OF  REFRACTION  AND  ACCOMMODATION. 

theria  or  any  debilitating  disease,  tonics  must  be  our  chief  remedy.  In 
the  rheumatic  form  (due  to  exposure  to  cold  or  draught)  or  the 
syphilitic,  iodide  and  bromide  of  potassium  are  of  much  use,  as  also  a 
suppurating  blister  behind  the  corresponding  ear.  I  have  often  found 
the  most  marked  and  speedy  benefit  from  the  latter  remedy,  so  that  a 
patient,  who  before  could  only  decipher  letters  of  14  or  16  of  Jager, 
was  able,  within  24  or  48  hours  after  the  application  of  the  blister,  to 
read  the  finest  print.  I  have  also  used  the  solution  of  the  extract  of 
Calabar  bean  with  excellent  results.  I  employ  it  of  a  strength  sufficient 
to  cause  considerable  contraction  of  the  ciliary  muscle  and  constrictor 
pupillae,  without,  however,  over- straining,  and  thus  fatiguing,  these 
muscles.  I  then  allow  the  effect  to  pass  off  entirely,  and  after  a  few 
days'  rest,  the  extract  is  re-applied,  so  that  the  muscles  may  be  periodi- 
cally stimulated.  The  action  of  the  Calabar  bean,  and  its  peculiar 
effect  upon  the  pupil  were  fully  investigated  in  1862,  by  Dr.  Fraser,* 
in  his  valuable  graduation  thesis  for  the  University  of  Edinburgh,  on 
the  "  Characters,  Actions,  and  Therapeutic  uses  of  the  Ordeal  Bean  of 
Calabar."  And  in  1863,  Dr.  Argyle  Robertson  discovered  its  effect 
upon  the  accommodation. f 

On  the  application  of  a  minute  quantity  of  a  strong  solution  (1 
drop  =  4  grains  of  the  bean)  to  the  inside  of  the  lower  eyelid,  a  little 
irritation  and  redness  are  produced,  but  these  pass  off  very  rapidly. 
Within  five  or  ten  minutes  the  pupil  begins  to  contract,  and  at  nearly 
the  same  time,  the  spasm  of  the  ciliary  muscle  commences.  The  contrac- 
tion of  the  pupil  reaches  its  maximum  degree  (about  1'"  in  diameter)  in 
from  30  to  45  minutes.  After  two  or  three  hours  it  gradually  dilates 
ao-ain,  but  does  not  regain  its  normal  size  till  after  the  lapse  of  two  or 
three  days,  when  it  may  even  become  larger  than  before.  Even  during 
its  greatest  contraction,  the  pupil  is  still  under  the  influence  of  light. 

The  spasm  of  the  accommodation  commences  about  the  same  time 
as  the  contraction  of  the  pupil,  and  both  the  near  and  far  point  become 
greatly  approximated  to  the  eye,  which  becomes,  in  fact,  strongly 
m^yopic.  The  far  point  in  the  emmetropic  eye  may  be  brought  to  5" 
or  6"  from  the  eye,  and  the  near  point  to  3"  or  3^".  The  effect  upon 
the  accommodation  passes  off  much  sooner  than  that  upon  the  pupil, 
for  three  or  four  hours  generally  suffice  to  restore  the  state  of  refraction 
and  accommodation  to  its  normal  condition. 

*  Further  investigations  on  the  physiological  action  of  the  Calabar  bean  are  con- 
tained in  a  more  recent  paper  by  Dr.  Fraser,  in  the  "  Transactions  of  the  Royal 
Society  of  Edinburgh,"  vol.  21. 

t  Shortly  after  this  discovery  of  Dr.  Argyle  Robertson,  I  had  tlie  opportunity 
of  carefully  studying  the  effect  of  the  Calabar  bean  upon  a  case  of  paralysis  of  the 
ciliary  muscle ;  a  full  account  of  which  will  be  found  in  the  "  Med.  Times  and 
Gazette,"  May  16,  1863. 


PARALYSIS,   ETC.,   OF   THE   CILIARY   MUSCLE.  541 

That  the  spasm  of  accommodation  is  due  to  the  action  of  the  drug 
upon  the  muscles  of  accommodation,  and  not  upon  the  iris,  was  incon- 
trovertibly  proved  by  Von  Graefe,*  who  tried  its  effect  in  a  case  of 
complete  absence  of  the  iris,  and  found  that  the  action  upon  the  accom- 
modation took  place  at  about  the  same  time,  and  in  exactly  the  same 
manner,  as  in  eyes  in  which  the  iris  was  present.  This  action  of  the 
Calabar  bean  is,  therefore,  exerted  upon  the  ciliary  muscle,  and  is  com- 
pletely independent  of  its  effect  upon  the  iris. 

The  effect  of  the  Calabar  bean  in  counteracting  the  action  of  atro- 
pine, has  also  been  proved  by  many  experiments.  The  weaker  solutions 
of  atropine  are  easily  overcome  by  a  strong  solution  of  Calabar.  But 
the  complete  paralysis  of  the  accommodation  by  a  strong  solution  of 
atropine  (4  grains  to  the  ounce)  is  only  temporarily  overcome  even  by 
a  very  strong  solution  of  Calabar,  1  drop  =  4  grains  ;  the  pupil  becomes 
smaller,  and  the  state  of  refraction  increased,  but  the  action  of  the  atro- 
pine re-asserts  itself  in  the  course  of  a  few  hours.  In  such  cases,  we 
must  repeat  the  application  of  the  Calabar  when  necessary,  until  the 
effect  of  the  atropine  upon  the  accommodation  has  disappeared.f 

Great  fatigue  of  the  ciliary  muscle  through  over  exertion  at  near 
objects,  may  give  rise  to  very  severe  symptoms  of  asthenopia,  and  this  is 
best  treated  by  the  use  of  strong  convex  glasses  (6  to  10  inches  focus), 
for  reading,  etc.  After  they  have  been  used  for  some  time,  the  accom- 
modation should  be  gradually  exercised  by  using  weaker  glasses,  the  dis- 
tance of  the  object  remaining  the  same.  The  accommodation  may  also 
be  rested  by  the  application  of  a  strong  solution  of  atropine  continued 
for  some  little  time. 

Sjy^ism  of  the  ciliary  muscle  is  of  rather  rare  occurrence,  and  is  espe- 
cially met  with  in  cases  of  hypermetropia  in  youthful  persons,  who 
have  strained  their  eyes  without  using  convex  glasses  ;  this  continued 
tension  of  the  accommodation  producing  a  spasmodic  contraction  of  the 
ciliary  muscle.  In  such  cases,  we  find  that  the  patient  is  apparently 
suffering  from  myopia,  requiring  concave  glasses  for  distant  objects, 
and  yet,  on  examining  his  eye  with  the  ophthalmoscope,  the  refraction  is 
found  to  be  hypei-metropic.  The  use  of  a  strong  solution  of  atropine  has 
frequently  to  be  continued  for  several  days,  before  the  ciliary  muscle 
can  be  completely  paralysed.  This  paralysis  and  complete  rest  of  the 
accommodation  must  be  continued  for  several  weeks. 

*  "A.  f.  0.,"ix,  3,  113. 

t  Listead  of  the  extract,  the  more  elegant  preparation  of  the  gelatine  discs  may 
be  employed.  But  these  do  not  answer  so  well  when  we  wish  to  stimulate  the 
partially  paralysed  muscle,  as  we  cannot  regulate  the  strength  so  exactly  as  in  the 
solution. 


542  ANOMALIES   OF   REFRACTION  AND   ACCOMMODATION. 

10.— SPECTACLES. 

The  spectacles  wliicli  ai-e  generally  used  for  the  purpose  of  correct- 
ing some  optical  defect  in  the  eye  are  either  spherical  or  cylindrical 
lenses,  or  a  combination  of  both.  The  properties  of  such  lenses  have 
been  already  sufficiently  explained  (pp.  489  and  534)  and  I  shall,  there- 
fore, now  only  add  a  few  remarks  as  to  the  different  kinds  of  spectacles 
and  their  construction. 

Erom  the  perusal  of  the  different  anomalies  of  refraction  and  accom- 
modation, the  reader  will  have  been  sufficiently  impressed  with  the 
importance  of  the  proper  and  scientific  selection  of  spectacles.  I  have 
no  hesitation  in  saying  that  the  empirical,  haphazard  plan  of  selection 
generally  employed  by  opticians,  is  but  too  frequently  attended  by  the 
worst  consequences  ;  and  that  eyes  are  often  permanently  injured,  which 
might,  by  skilful  treatment,  have  been  preserved  for  years.  For  this 
reason,  I  must  strongly  urge  upon  medical  men  the  necessity  of  not 
only  examining  the  state  of  the  eyes,  and  ascertaining  the  exact  nature 
of  the  affection  of  refraction  or  accommodation,  but  of  going  even  a 
step  further  than  this,  and  determining  with  care  and  accuracy  the 
number  of  the  required  lens.  For  this  purpose  they  must  possess  a 
case  of  trial-glasses,*  containing  a  complete  assortment  of  concave  and 
convex  lenses,  glasses  of  corresponding  number  being  kept  by  the 
optician.  Written  directions  as  to  the  focal  distance  of  the  required 
glass,  and  whether  it  is  for  distance  or  for  reading,  are  to  be  sent  to  the 
optician. 

The  strength  of  any  given  convex  lens  may  be  easily  ascertained  by 
finding  the  distance  at  which  the  image  of  a  distant  object  (a  candle, 
the  bars  of  a  window  frame,  etc.),  is  distinctly  formed  on  a  sheet  of 
white  paper  or  the  wall.  The  distance  of  this  distinct  image  from  the 
lens,  gives  the  focal  length  of  the  latter.     But  if  we  have  a  set  of  trial 

*  Such  trial  cases  are  made  by  Messrs.  Paetz  aud  Flolir,  of  Berlin,  and  contain 
complete  sets  of  concave  and  convex  lenses,  prismatic  and  tinted  glasses,  and  a 
clip  spectacle  frame  for  holding  the  lenses.  These  lenses  are  defined  in  the  Prussian 
inches,  which  are  almost  identical  with  the  English  ;  whereas  the  French  are  con- 
siderably more.  As  the  arrangement  of  the  lenses  in  these  trial  cases  is,  however, 
made  without  any  system,  so  that  whilst  there  are  very  many  and  but  slight 
gradations  in  the  weaker  glasses,  those  in  the  stronger  are  not  sufficiently  numerous, 
the  difference  in  the  refraction  of  the  higher  niimbers  is  very  great.  Thus,  whilst 
the  dill'erence  in  the  refraction  between  convex  60  and  50  is  only  -g^,  that  between 
3^  and  3  is  ^.  To  remedy  these  defects,  as  well  as  to  simplify  the  trial  cases,  and 
greatly  diminish  the  number  of  lenses,  Zehender  has  projoosed  a  new  combination 
scale  of  glasses  (vide  "Klin.  Monats.,"  1866).  As  a  member  of  the  International 
Refraction  Committee,  appointed  by  the  Ophthalmological  Congress  in  1867,  I  may 
nietition  here,  that  it  is  very  probable  that  the  metre  measiu'c  will  be  substituted  for 
that  of  indies  in  the  determination  of  the  strength  of  lenses,  in  order  that  their 
number  may  be  the  same  in  all  countries. 


SPECTACLES.  543 

glasses  at  hand,  a  more  simple  and  ready  mode  is  to  find  the  concave 
lens  whieli  completely  neutralizes  the  convex  one,  and  this  at  once  gives 
us  the  number  of  the  latter. 

The  complete  neutralization  of  the  convex  lens  by  the  concave  is 
known  by  the  fact  that  if  the  two  are  placed  in  close  apposition,  we  can 
read  as  well  through  them  as  without  any  glass  before  the  eye.  Another 
test  is,  that  if  we  regard  a  vertical  line  {e.g.,  the  vertical  bar  of  a  window) 
through  them,  it  remains  perfectly  immoveable  when  the  glasses  are 
moved  to  and  fro  before  the  eye.  Whereas,  the  line  will  distinctly  move 
if  the  two  glasses  do  not  neutralize  one  another,  the  more  so,  the  greater 
the  difierence  between  them.  If  the  object  moves  in  the  contrary  direc- 
tion to  that  in  which  the  lenses  are  moved,  it  proves  that  the  convex 
lens  is  the  stronger  of  the  two  ;  whereas,  if  it  moves  in  the  same  direc- 
tion, the  concave  is  the  stronger.  The  strength  of  concave  lenses  may 
be  tried  in  the  same  way. 

Care  should  be  taken  that  the  spectacles  fit  accurately ;  that  the 
glasses  are  on  the  same  level,  so  that  one  is  not  higher  than  the  other ; 
that  they  are  sufiiciently  close  to  the  eyes,  and  that  the  centre  of  each 
glass  is  exactly  opposite  the  centre  of  the  pupil.  The  last  point  should 
be  particularly  observed  in  the  selection  of  glasses  which  fit  on  to  the 
nose  by  means  of  a  spring  (pinces  ncz),  for  we  find  that,  on  account  of 
their  oval  shape,  these  generally  are  not  accurately  centred.  If  they  do 
not  fit  properly,  so  that  their  centre  corresponds  to  the  centre  of  the  pupil, 
they  act  as  prisms,  and  give  rise  to  diplopia  or  a  correcting  squint,  and 
the  latter  may  even  become  permanent,  if  their  use  is  persisted  in. 
Concave  glasses  should  be  quite  close  to  the  eye,  otherwise  they  will 
diminish  the  size  and  distinctness  of  the  retinal  image.  As  the  rays 
which  impinge  upon  a  concave  lens  are  rendered  divergent  by  it,  it 
follows  that  the  further  the  glass  is  removed  from  the  eye,  the  fewer 
peripheral  rays  will  enter  the  latter,  in  consequence  of  which  the  retinal 
image  is  diminished  in  size  and  intensity.*  The  reverse  obtains  in  the 
case  of  convex  glasses,  for  as  they  render  the  rays  which  impinge  upon 
them  more  convergent,  a  greater  number  of  peripheral  rays  wiU  enter, 
the  further  (up  to  a  cei'tain  point,  of  course)  the  convex  glass  is  removed 
from  it,  the  retinal  image  becoming  at  the  same  time  larger  and 
brighter. 

Single  eye  glasses  should  not,  as  a  rule,  be  permitted,  as  they  often 
lead  to  weakness  of  the  other  eye  from  non-use. 

Besides  the  spherical  and  cylindi-ical  spectacles  we  must  also  con- 
sider the  following  kinds  : — 

*  It  has  already  been  stated  that  concaye  glasses  diuiiuisli  the  retinal  image  by 
moving  the  nodal  point  further  back,  thus  diminishing  the  angle  of  vision  ; 
whereas,  convex  glasses  enlarge  the  retinal  image,  as  they  move  the  nodal  point  for- 
wards, and  thus  increase  the  size  of  the  angle  of  vision. 


544  ANOMALIES  OF   REFRACTION   AND   ACCOMMODATION. 

The  periscopic  glasses  consist  of  concavo-convex,  and  convexo- 
concave  lenses  (so  called  positive  and  negative  menisci),  and  conse- 
quently have  only  a  very  slight  spherical  aberration.  On  this  account, 
when  the  concave  surface  is  turned  towards  the  eye,  there  is  less 
irregular  refraction  at  the  edge  of  the  glass,  so  that  the  regularity  of 
the  images  is  much  less  impaired.  In  consequence  of  this,  the  observer 
can  look  more  obliquely  through  them,  as  was  first  shown  by  Wollaston, 
who  on  this  account  termed  them  periscopic.  Their  chief  disadvantages 
are  that  they  reflect  the  light  more,  and  are  also  more  heavy  and  ex- 
pensive than  spherical  lenses. 

Spectacle  glasses  are  sometimes  required  to  have  a  different  focus 
in  the  upper  and  lower  part  (^pantoscopic  spectacles).  This  is  more 
especially  the  case  if  presbyopia  co-exists  with  myopia  or  hypermetropia. 
Thus  Franklin,  who  was  presbyopic  and  also  slightly  myopic,  employed 
glasses,  the  lower  half  of  which  was  convex,  to  neutralize  the  presby- 
opia, and  the  upper  half  concave,  to  neutralize  the  myopia.  In  Paris 
such  glasses  are  termed  verves  a  douhle  foyer,  and  are  constructed  by 
grinding  in  the  upper  part  of  the  spectacle-glass,  the  surface  which  is 
turned  from  the  eye,  with  another  radius.  Such  spectacles  must  be 
placed  at  a  proper  height  before  the  eyes,  so  that  in  looking  at  near 
objects  the  rays  only  fall  upon  the  eye  through  the  lower  part,  whereas, 
those  from  distant  objects  must  only  fall  upon  the  upper  part.  This 
form  of  spectacle  is  found  very  useful  by  miniature  painters,  lecturers, 
etc. 

Prismatic  spectacles  are  sometimes  employed  either  for  the  purpose 
of  exercising  and  thus  strengthening  certain  of  the  muscles  of  the  eye- 
ball, or  to  relieve  them.  The  action  of  prisms  has  been  already  ex- 
plained in  the  introduction  (p.  10),  and  the  use  of  prismatic  spectacles 
will  be  found  described  in  the  article  upon  muscular  asthenopia.  The 
prisms  are  generally  turned  with  their  base  inwards  (to  relieve  the 
internal  recti  muscles),  and  may  either  be  used  alone  or  in  combination 
with  convex  or  concave  lenses.  In  the  latter  case,  they  are  ground  in  such 
a  manner  as  to  combine  the  effect  of  a  prism  with  that  of  a  spherical 
lens.  By  turning  the  base  of  the  prism  inwards,  the  rays  will  be 
deflected  somewhat  to  the  inner  side  of  the  yellow  spot,  the  eye  will 
consequently  move  slightly  outwards  so  as  to  bring  the  rays  again  upon 
the  yellow  spot ;  there  will  consequently  be  a  less  convergence  of  the 
optic  axes,  the  effect  being  the  same  as  if  the  object  were  placed  some- 
what further  off,  but  it  is  seen  under  the  same  visual  angle,  and  diver- 
gence of  the  rays  is  also  the  same. 

Closely  allied  to  the  prismatic  glasses,  are  the  decentred  lenses  of 
Giraud  Teulon.  They  are  constructed  in  such  a  manner,  that  the 
eccentric  portions  of  two  convex  lenses  are  used  instead  of  the  centre,  so 
that  they  may  thus  acquire  a  slightly  prismatic  action.     Thus  in  convex 


SPECTACLES.  545 

lenses  the  centre  sliould  lie  a  little  to  the  inner  side  of  the  visual  lines, 
whereas  in  concave  glasses  the  reverse  obtains,  and  the  centre  should 
lie  a  little  to  the  outer  side  of  the  visual  lines. 

Dr.  Scheffler  proposes  to  substitute  for  the  common  spherical  lenses, 
glasses  which  are  cut  out  from  the  periphery  of  a  lai'ge  lens,  in  such  a 
manner  as  to  act  as  decentred  lenses.  The  advantage  which  he  claims 
for  them  is,  that  with  them  the  convergence  of  the  optic  axes  undergoes 
an  alteration  in  harmony  with  the  change  in  the  accommodation,  which 
is  not  the  case  when  the  common  spherical  lenses  are  used.  His  Avork 
"  Die  Theorie  der  Augenpfehler  and  der  Brille,"  in  which  this  subject  is 
fully  treated,  is  being  translated  into  English  by  Mr.  R.  B.  Carter. 

Eye-protectors  are  found  of  much  service  to  guard  the  eye  against 
very  bright  light,  dust,  or  cold  winds.  The  best  are  the  medium  blue 
curved  eye-protectors.  They  are  curved  somewhat  like  a  watch  glass, 
so  as  to  fit  closely,  except  at  the  temporal  side,  where  they  permit  a 
sufficient  amount  of  air  to  enter  and  come  in  contact  with  the  eye,  to 
maintain  the  evaporation  of  the  conjunctival  moisture.  They  are 
greatly  to  be  preferred  to  the  goggles  with  wire  or  silk  sides,  or  the 
glass  spectacles  with  large  glass  side  pieces,  for  these  keep  the  eye 
much  too  hot  and  close.  The  goggles  are  useful  if  the  patient  is 
exposed  to  the  atmosphere  very  soon  after  a  severe  operation,  when 
the  eye  is  still  inflamed  and  very  susceptible  to  cold,  but  for  all  other 
purposes  the  cuiwed  glasses  are  to  be  preferred. 

The  sense  of  dazzling  of  which  many  (more  especially  myopic) 
patients  complain  when  they  are  exposed  to  bright  sun  or  gas  light,  is 
most  effectually  relieved  by  cobalt  blue  glasses.  It  was  formerly  supposed 
that  the  red  rays  of  the  solar  spectrum  were  the  most  trying  to  the 
eye,  and  consequently  green  glasses  (which  exclude  the  red  rays)  were 
much  in  vogue.  But  it  is  now  a  well  known  fact,  that  it  is  not  the  red 
but  the  orange  rays  which  are  irritating  to  the  retina,  and  as  blue 
excludes  the  orange  rays  this  is  the  proper  colour  for  such  spectacles. 
Moreover,  the  blue  colour,  on  account  of  its  more  eccentric  position  in 
the  solar  spectrum,  makes  a  less  impression  upon  the  retina.  Smoke- 
glasses  are  not  so  good,  as  they  more  or  less  subdue  and  diminish  the 
whole  volume  of  light  and  colour,  and  thus  render  the  image  somewhat 
indistinct. 

It  is  often  very  desirable  to  combine  the  blue  tint  with  the  use  of 
convex  or  concave  spherical  lenses  ;  in  the  weaker  glasses  tbis  can  be 
very  effectually  done,  but  in  the  higher  numbers  it  is  difficult,  for  the 
varying  thickness  of  the  glass  causes  a  considerable  difference  in  the 
tint  in  the  centre  and  at  the  edges  of  the  lens.  In  such  cases,  it  will  be 
well  to  adopt  Mr.  Laurence's  suggestion,  viz.,  to  join  a  very  thin  piece 
of  plain  tinted  glass  with  Canada  balsam,  to  the  back  of  a  coloui'lcss 
spherical  lens. 

2   N 


540  ANOMALIES   OF   REFRACTION   AND   ACCOMMODATION. 

Besides  the  coloured  eye-protectors  which  are  used  in  order  to 
diminish  the  bright  glare  of  light,  or  to  keep  off  the  cold  wind,  dust, 
etc.,  there  are  those  which  are  used  by  workmen  in  order  to  protect  the 
eye  during  their  work  against  injury  from  pieces  of  stone,  chips  of  steel, 
etc.  The  best  are  those  made  of  thick  plate  glass,  with  wire  or  gauze 
sides,  for  they  are  sufficiently  strong  to  resist  the  force  of  any,  excepting 
a  very  large  projectile.  The  chief  objections  to  these  are  their  expense 
and  their  weight.  To  obviate  these  defects,  Dr.  Cohn*  has  recom- 
mended the  use  of  spectacles  made  of  mica  instead  of  glass.  If  the  mica 
is  of  good  quality,  it  is  quite  as  transparent  as  glass,  but  lends  a 
faint  grey  tint  to  objects,  which  does  not,  however,  in  the  least  diminish 
the  acuity  of  vision,  but  rather  tempers  the  Hght.  They  are  made  in 
the  shape  of  the  large  cui-ved  eye-protectors,  and  should  fit  quite  close 
to  the  eye,  leaving  only  the  temporal  side  somewhat  open.  They  are 
much  lighter  and  cheaper  than  the  glass  spectacles,  and  do  not  break 
on  fallina'  down. 


11.— DIFFERENCE  IN  THE  REFRACTION  OF  THE  TWO  EYES. 

Differences  in  the  refraction  of  the  two  eyes  are  not  of  unfrequent 
occurrence,  and  generally  consist  in  differences  in  the  degree  of  the 
myopia  or  hypermetropia  in  the  two  eyes  ;  or,  again,  one  eye  may  be 
emmetropic,  the  other  myopic  or  hypermetropic  ;  or  myopia  niay  exist  in 
one  eye,  and  hypermetropia  in  the  other.  Absence  of  the  lens  (aphakia) 
in  one  eye,  gives  rise  of  course  to  a  very  great  difference  in  the  state  of 
refraction  of  the  two  eyes.  In  the  majority  of  cases,  the  refraction  of 
the  two  eyes  is  very  neai'ly  alike.  Sometimes,  however,  we  find  con- 
siderable differences  in  the  degree  of  myopia  or  hypermetropia.  The 
practical  qu.estion  is,  what  kind  of  glasses  are  we  to  give  to  such 
patients  ?  It  might  appear  proper  to  fui'nish  each  eye  with  the  glass 
suitable  to  its  own  state  of  refraction,  but  in  practice  we  find  that  this 
does  not  generally  answer,  for  the  patients,  as  a  rule,  complain  that  such 
spectacles  render  their  vision  confused  and  indistinct,  on  account  of  the 
difference  in  the  size  of  the  two  retinal  images.  It  is  best,  therefore, 
to  furnish  both  eyes  with  the  glass  which  suits  the  least  ametropic 
(hypermetropic  or  myopic)  eye.  If  it  is  very  desirable  that  the  patient 
should  enjoy  the  greatest  possible  acuteness  of  vision,  we  may  give  two 
different  glasses,  so  as  completely  to  neutralize  the  difference  in  the 
state  of  i-efraction,  and  the  patient  must  try  whether  he  is  able  to  see 
distinctly  and  comfortably  with  them.  Sometimes  a  little  practice  will 
enable  him  to  do  so,  and  then  their  use  may  be  allowed.     If  this  is  not 

*  Eerliuer  Kliuische.     Woclieusclirift,  Feb.  24,  1868. 


DIFFERENCE   IN    THE    REFRACTION   OF    THE   TWO   EYES.         547 

the  case,  we  may  partially  neutralize  the  difference,  and  thus  diminish 
the  size  of  the  circles  of  diffusion.  Thus  if  the  myopia  of  the  one 
eye  ^  -j-ji  ^^^  ^^^^  of  the  other  -g-,  we  may  prescribe  concave  15  for  the 
former,  and  concave  9  or  10  for  the  latter.  It  has  also  been  advised 
that  when  the  sight  of  the  two  eyes  (which  differ  considerably  in  the 
degree  of  their  myopia)  is  equally  good,  the  ^lass  which  lies  midway 
between  the  two  degrees  of  myopia  should  be  given  for  both.  If, 
for  instance,  the  one  eye  requires  concave  4  and  the  other  concave  8,  it 
would  be  advisable  to  prescribe  concave  6  "for  both  eyes.  But  such 
glasses  prove  unsuitable,  as  they  suit  neither  eye,  being  too  strong  for 
the  one,  and  too  weak  for  the  other. 

If  there  is  a  difference  in  the  refraction  of  the  two  eyes — the  one 
being  myopic,  the  other  hypermetropic — it  is  also  often  difficult  to 
suit  them  with  glasses  which  shall  neutralize  each  anomaly.  This  is 
owing  to  the  difference  in  the  size  of  the  retinal  images  which  will  be 
produced,  for  the  convex  lens  will  enlarge,  the  concave  lens  diminish, 
the  size  of  the  retinal  image,  and  this  may  prove  a  source  of  consider- 
able confusion.  In  all  cases  of  difference  in  the  refraction  of  the 
two  eyes,  the  patients  should  try  the  glasses  for  some  little  time,  so  as, 
if  possible,  to  become  accustomed  to  them,  before  we  decide  definitely 
as  to  the  kind  of  glasses  which  we  shall  prescribe. 


CHArTER   XIV. 

AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE.'^ 


1.— ACTIONS  OF  THE  MUSCLES  OP  THE  EYE. 

In  order  properly  to  understand  the  physiological  action  of  the  different 
muscles  of  the  eyeball,  we  must  consider  the  eye  as  a  sphere,  the 
centre  of  which  being  fixed,  its  movements  can  only  be  rotations  around 
a  fixed  axis,  and  hence  there  can  be  no  change  of  locality.  But  for 
the  purpose  of  accurately  determining  these  rotations,  it  does  not  suffice 
to  ascertain  the  change  of  position  which  one  point  upon  the  surface  of 
the  sphere  may  undergo,  but  we  must  take  into  consideration  the 
position  of  a  second  point,  which  must  not,  however,  stand  in  the  rela- 
tion of  a  pole  to  the  first.  If  we  take  the  centre  of  the  cornea  for  the 
one  point,  and  the  vertical  meridian  (the  greatest  circle  standing  per- 
pendicular to  the  equator  of  the  eye)  as  the  second,  we  shall  be  easily 
able  to  determine  the  rotations  which  the  eye  undergoes,  by  watching 
in  which  direction  the  centre  of  the  cornea  moves,  and  what  kind  of 
inclination  the  vertical  meridian  undergoes. 

For  the  purpose  of  discovering  the  inclination  of  the  vertical 
meridian  in  the  different  positions  of  the  eye,  Donders  devised  the  fol- 
lowing ingenious  experiment.  Having  vertically  suspended  a  coloured 
thread,  he  looked  at  it  until  its  image  was  impressed  upon  his  retina 
(this  image  was  of  coarse  in  the  vertical  meridian  of  the  eye),  he  then 
moved  his  head  in  the  different  directions  in  which  he  desired  to  ascer- 
tain the  inclinations  of  the  vertical  meridian,  and  then  measured  the 
angle  which  the  image  upon  his  retina  formed  with  a  line  held  verti- 
cally before  his  eye.  As  the  position  of  the  retinal  image  of  course 
agreed  with  that  of  the  vertical  meridian,  he  was  enabled  in  this  way 
readily  to  ascertain  the  direction  of  the  vertical  meridian  in  every 
movement  of  the  eyeball. 

*  For  further  inforumtion  upon  the  diseases  of  the  muscles  of  the  eye,  I  must 
refer  the  reader  to  Von  Graefe's  articles  in  the  "A.  f.  O.,"  vols,  i  and  iii ;  and  Alf. 
Graefc's  "  Motililiits-storungen  des  Auges  ;"  also  to  my  articles  in  the  "  R.  L.  O.  H. 
Rep.,"  vols,  ii  and  iii ;  and  in  the  "  Med.  Times  and  Gazette,"  1865. 


ACTIONS  OF   THE   MUSCLES   OF   THE   EYE.  549 

I  must  here  point  out  that  from  habit  we  see  objects  vertical  and 
not  slanting,  even  although  the  vertical  meridian  should  be  inclined. 

Based  upon  these  experiments,  Bonders  laid  down  the  following 
rules  as  to  the  position  of  the  vertical  meridian  in  the  different  move- 
ments of  the  eye : — 

1.  In  looking  in  the  horizontal  meridian-plane,  straightforwards,  to 
the  right  or  to  the  left,  the  vertical  meridian  suffers  no  inclination,  but 
i-emains  vertical. 

2.  In  looking  in  the  vertical  meridian-plane,  straightforwards,  up- 
wards, or  downwards,  the  vertical  meridian  also  remains  vertical. 

3.  In  looking  diagonally  upwards  to  the  left,  the  vertical  meridians 
of  both  eyes  are  inclined*  parallelly  to  the  left  (that  of  the  left  eye 
slanting  outwards,  that  of  the  right  inwards). 

4.  In  looking  diagonally  downwards  to  the  left,  the  vertical  meri- 
dians of  both  eyes  are  inclined  parallelly  to  the  right  (that  of  the  left 
eye  inwards,  that  of  the  right  outwards). 

5.  In  looking  diagonally  upwards  to  the  right,  the  vertical  meridians 
of  both  eyes  are  inchned  parallelly  to  the  right  (that  of  the  right  eye 
outwards,  that  of  the  left  inwards). 

6.  In  looking  diagonally  downwards  to  the  right,  the  vertical 
meridians  of  both  eyes  are  inclined  parallelly  to  the  left  (that  of  the 
right  eye  inwards,  that  of  the  left  eye  outwards). f 

For  the  sake  of  simplicity,  we  may  consider  the  muscles  which 
move  the  eyeball  as  consisting  of  three  pairs  ;  the  two  muscles  of  each 
pair  acting  in  an  antagonistic  way  to  each  other. 

In  order  to  ascertain  the  direction  in  which  a  muscle  acts,  we  must 
draw  through  it  a  straight  line  which  shall  unite  the  middle  of  its 
origin  with  the  middle  of  its  insertion.  A  plane  laid  through  this  line 
and  the  turning-point  of  the  eye,  is  termed  the  plane  of  the  muscle 
(muscle-j}lane) ,  and  a  line  standing  perpendicular  upon  this  plane  in  the 
turning-point,  is  called  the  axis  of  turning.  Now  we  shall  find  it  of  the 
greatest  importance  in  the  paralyses  of  the  different  muscles  of  the  eye- 
ball, to  know  in  which  positions  of  the  eye  certain  muscles  act  most  upon 
the  height  of  the  cornea,  and  in  which  positions  most  upon  the  vertical 
meridian.  We  shall  find  that  the  effect  upon  the  height  of  the  cornea 
is  the  greater,  the  more  the  muscle-plane  coincides  with  the  vertical 
meridian-plane,  and  the  more  the  axis  of  turning  approaches  the  hori- 
zontal diameter.  On  the  other  hand,  the  power  over  the  vertical  meridian 
will  be  least  in  this  position,  but  will  increase  in  proportion  as  the  eye 
is  turned  in  the  opposite  direction,  for  the  axis  of  turning  then  ap- 
proaches more  and  more  the  position  of  the  optic  axis. 

*  The  upper  end  of  tlie  vertical  meridian  line  is  the  one  always  described. 
t  These  rules  have  been  translated  from  Alfred  Graefe's  excellent  work,  "  Klin- 
ische  Analyse  der  Motilitats-storungeu  des  Auges." 


550       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

Let  US  noAv  consider  the  action  of  the  diflferent  muscles  upon  the 
position  of  the  eyeball  and  the  direction  of  the  vertical  meridian. 

The  superior  rectus  muscle  arises  from  the  portion  of  bone  just  in 
front  of  the  optic  foramen,  and  runs  obliquely  over  the  globe  to  be 
inserted  into  the  sclerotic,  about  three  lines  from  the  cornea.  But  its 
course  is  so  oblique,  that  the  internal  portion  of  its  insertion  lies  almost 
one  line  nearer  the  cornea  than  its  external  portion.  Its  action  is  to 
move  the  eye  upwards  and  shghtly  inwards,  inclining  the  vertical 
meridian  inwards. 

The  inferior  rectus  also  arises  from  the  optic  foramen,  and  its  tendon 
is  inserted  about  three  lines  from  the  lower  edge  of  the  cornea,  but 
somewhat  (about  half  a  line)  to  the  inner  side  of  a  supposed  vertical 
line  drawn  through  the  centre  of  the  cornea.  It  moves  the  eye  down- 
wards and  inwards,  and  inclines  the  vertical  meridian  outwards. 

The  superior  and  inferior  recti  exert  most  influence  upon  the  height 
of  the  cornea,  when  the  eye  is  turned  outwards,  as  the  muscle-plane 
then  coincides  more  and  more  with  the  meridian-plane,  and  the  axis  of 
turning  approaches  the  horizontal  diameter.  These  muscles  act  most 
upon  the  inclination  of  the  vertical  meridian,  when  the  eye  is  tiu-ned 
inwards,  as  the  axis  of  turning  then  approaches  more  and  more  the 
optic  axis. 

The  external  rectus  arises  from  the  common  tendon,  and  runs  along 
the  outer  side  of  the  eyeball  to  be  inserted  about  three  lines  from  the 
external  edge  of  the  cornea.  It  moves  the  eye  directly  outwards,  with- 
out producing  any  inclination  of  the  vertical  meridian. 

The  internal  rectus  is  the  strongest  of  the  ocular  muscles  and  nearly 
four  Hnes  in  width  ;  it  arises  from  the  common  tendon,  and  is  inserted 
into  the  sclerotic  about  2^  lines  from  the  inner  edge  of  the  cornea.  It 
moves  the  eye  directly  inwards,  and  does  not  inchne  the  vertical 
meridian. 

The  superior  oblique  arises  just  in  front  of  the  inner  portion  of  the 
optic  foramen,  and  runs  along  towards  the  inner  angle  of  the  eye,  where 
its  tendon  passes  through  the  trochlea,  and  then,  bending  outwards  and 
backwards,  it  spreads  out  like  a  fan  to  be  inserted  into  the  upper,  outer 
and  posterior  quadrant  of  the  eyeball,  by  a  tendon  three  lines  in  length, 
the  convexity  of  which  looks  backwards.  The  action  of  the  superior 
obHque  is  to  roll  the  eye  downwards  and  outwards,  and  to  incline  the 
vertical  meridian  inwards. 

The  inferior  oblique  arises  from  a  depression  in  the  orbital  edge  of 
the  superior  maxillary  bone,  slightly  towards  the  outer  side  of  the 
lachrymal  sac,  and  passes  along  the  floor  of  the  orbit  in  an  outward, 
downward,  and  backward  direction,  until  it  has  passed  beneath  the 
inferior  rectus  (to  which  it  is  connected  by  fibro-cellular  tissue),  when 
it  curves  upwards  and  backwards,  and  passes  to  the  inner  side  of  the 


ACTIONS   OF   THE   MUSCLES   OF   THE   EYE.  551 

external  rectus,  to  be  inserted  by  a  short  tendon  close  to  tlie  insertion  of 
the  superior  oblique.  The  inferior  oblique  rolls  the  eye  upwards  and 
outwards,  and  inclines  the  vertical  meridian  outwards.  .  The  two  oblique 
muscles  act  most  upon  the  height  of  the  cornea  when  the  eye  is  moved 
inwards,  as  theii*  muscle-plane  then  coincides  raore  and  more  with  the 
meridian-plane ;  w^hcreas,  they  act  most  upon  the  inclination  of  the 
vertical  meridian  when  the  eye  is  turned  outwards,  for  then  the  axis  of 
turning  approaches  more  and  more  the  optic  axis. 

Having  described  the  action  of  the  individual  muscles,  we  must  now 
pass  on  to  the  consideration  of  the  movements  of  the  eye  which  are 
produced  by  the  combined  action  of  several  muscles.  In  so  doing,  we 
have  to  consider  the  following  eight  different  movements  of  the  eye : — 

1.  The  movement  vertically  upwards,  in  which  the  vertical  meridian 
remains  vertical,  is  brought  about  by  the  action  of  the  superior  rectus 
and  i:iferior  oblique.  The  superior  rectus  alone,  draws  the  cornea 
upwards  and  inwards,  and  inclines  the  vertical  meridian  inwards,  hence 
some  other  muscle  (inferior  oblique),  whose  action  is  to  draw  the 
cornea  upwards  and  outwards  and  incline  the  vertical  meridian  out- 
wards, must  associate  itself  with  the  superior  rectus,  in  order  to 
counterbalance  its  action. 

2.  In  moving  the  eye  diagonally  upwards  and  inwards,  the  vertical 
meridian  being  inclined  inwards,  the  superior  rectus  is  chiefly  associated 
with  the  internal  rectus.  But  as  the  latter  has  no  effect  upon  the 
vertical  meridian,  the  superior  rectus  would  incline  it  too  much  inwards, 
and  hence  disturb  its  parallelism  with  the  vertical  meridian  of  the 
other  eye  (which  is  inclined  outwards).  Some  other  muscle,  whose 
action  is  to  incline  the  vertical  meridian  outwards,  must,  therefore,  be 
called  into  play,  in  order  to  check  the  action  of  the  superior  rectus. 
We  shall  again  find  in  the  inferior  oblique  the  muscle  required ;  more- 
over, on  account  of  its  having  least  influence  on  the  vertical  meridian 
when  the  eye  is  turned  upwards  and  inwards,  it  will  not  over-correct 
the  action  of  the  superior  rectus,  but  only  limit  it. 

3.  In  moving  the  eye  diagonally  upwards  and  outwards,  the  vertical 
meridian  being  inclined  outwards,  the  superior  rectus  acts  in  con- 
junction with  the  external  rectus.  But  as  the  latter  has  no  influence 
on  the  position  of  the  vertical  meridian,  and  as  the  internal  rectus 
turns  it  inwards,  we  must  call  into  requisition  some  other  muscle, 
which  shall  not  only  counterbalance  the  effect  of  the  superior  rectus 
upon  the  vertical  meridian,  but  shall  even  more  than  correct  it,  and 
incline  the  latter  outwards.  The  inferior  oblique  will  be  able  to  do 
this,  for  the  eye  is  now  in  the  position  (upwards  and  outwards)  in 
which  the  inferior  oblique  acts  most  upon  the  vertical  meridian. 

4.  The  movement  vertically  downwards,  the  vertical  meridian 
remaining  vertical,  is  produced  hy  the  combined  action  of  the  inferior 


ooz 


AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 


rectus  and  superior  oblique.  The  action  of  the  inferior  rectus  alone, 
would  be  to  draw  the  eye  downwards  and  inwards,  and  to  incline 
the  vertical  meridian  outwai-ds,  hence  it  must  be  associated  with  the 
superior  oblique,  whose  action  is  to  move  the  eye  downwards  and 
outwards,'  and  to  incline  the  vertical  meridian  inwards,  and  thus  to 
counterbalance  the  inferior  rectus. 

5.  In  the  movement  diagonally  downwards  and  inwards,  the  vertical 
meridian  being  inclined  outwards,  the  inferior  rectus  is  associated  with 
the  internal  rectus,  and  the  superior  oblique  is  required  to  limit  the 
effect  of  the  inferior  rectus  upon  the  vertical  m.eridian,  and  to  preserve 
the  parallelism  of  the  meridians. 

6.  In  the  movement  diagonally  downwards  and  outwards,  the 
vertical  meridian  being  inclined  inwards,  the  inferior  rectus  is  asso- 
ciated with  the  external  rectus,  and  the  superior  oblique  is  called  into 
play,  not  only  to  countei-balance  the  effect  of  the  inferior  rectus  upon 
the  vertical  meridian,  but  to  over-correct  this,  and  incline  the  latter 
inwards. 

7.  The  movement  directly  outwards  is  produced  by  the  action  of 
the  external  rectus. 

8.  The  movement  directly  inwards  is  produced  by  the  action  of  the 
internal  rectus. 

The  following  tabular  arrangement  will  enable  the  reader  to  remember 
more  easily  the  manner  in  which  the  different  movements  of  the  eye 
are  produced : — 


Movement. 

Upwards . 
Downwards 
Inwards  . 
Outwards 

Upwards  and  inwards 
Upwards  and  outwards 
Downwards  and  inwards 
Downwards  and  outwards 


Is  produced  by  tlie  action  of  the 

Superior  rectus  and  inferior  oblique. 

Inferior  rectus  and  superior  oblique. 

Internal  rectus. 

External  rectus. 
J  Superior    rectus,    internal 
(       inferior  oblique, 
j  Superior   rectus,    external 
\       inferior  oblique. 


Inferior    rectus,    internal 

superior  obHque, 
Inferior   rectus,     external 

superior  oblique. 


rectus, 
rectus, 
rectus, 
rectus, 


and 


and 


and 


and 


The  effect  of  the  recti  muscles  is  to  draw  the  eye  into  the  orbit,  that 
of  the  oblique  muscles  is  to  draw  it  out. 

The  nerves  supplying  the  muscles  of  the  eye,  are  the  third,  fourth, 
and  sixth. 

The  third  nerve  supplies  the  superior,  inferior,  and  internal  rectus, 


PARALYSIS   OF   THE   EXTERNAL   RECTUS  MUSCLE.  553 

the  inferior  oblique,  the  levator  palpebrte  superioris,  the  constrictor 
pupillas,  and  the  ciliary  muscle. 

The  fourth  nerve  supplies  the  superior  oblique. 

The  sixth  nei've  supplies  the  external  rectus. 

There  are  two  difi'erent  kinds  of  binocular  movements,  viz.,  the 
associated  and  the  accommodative.  In  the  former,  the  optic  axes 
(strictly  speaking  the  visual  lines)  remain  parallel,  whereas,  in  the 
accommodative  movements  they  converge  towards  each  other,  and 
meet  in  the  object.  When  the  muscles  of  both  eyes  are  quite  at  rest, 
the  angle  formed  by  the  visual  lines  of  the  two  eyes  is  called  the 
muscular  mesoropter  ;  and  the  convergence  of  the  visual  lines  is  such, 
that  their  prolongation  would  meet  at  a  point  varying  from  8'  to  12'  in 
front  of  the  eyes.  I  must  here  mention  the  fact,  that  in  looking  down- 
wards there  is  always  an  increased  tendency  to  convergence,  whereas,  in 
looking  upwards  there  is  a  greater  tendency  to  divergence.  Hence  a 
convergent  squint  becomes  more  marked  when  the  patient  looks  down- 
wards, and  a  divergent  squint  when  he  looks  upwards. 

"We  have  now  briefly  to  consider  the  symptoms,  diagnosis,  and 
treatment  of  the  paralytic  affections  of  the  different  muscles  of  the 
eye,  and  I  shall  commence  with  the  simplest  and  easiest  form  of 
paralysis,  viz.,  that  of  the  external  rectus  muscle. 

To  prevent  needless  repetition,  and  to  avoid  the  chance  of  any 
symptom  being  overlooked,  it  is  always  best  to  follow  a  certain 
routine  in  examining  patients  supposed  to  be  affected  with  strabismus, 
or  paralysis  of  one  or  more  of  the  muscles  of  the  eye.  Such  an 
examination  is  best  begun,  by  directing  the  patient  (who  should  hold 
his  head  quite  straight  and  immoveable)  to  follow  with  his  eyes  some 
object,  such  as  a  pen  or  ruler,  held  at  the  distance  of  a  few  feet,  and 
moved  in  all  directions.  Any  abnormality  in  the  movement  of  either 
eye  will  thus  become  at  once  apparent.  We  next  cover  one  eye  (say 
the  right)  with  our  hand,  the  patient  the  while  keeping  his  eyes 
steadily  fixed  upon  the  object,  and  we  then  observe  whether  the  left 
eye  remains  immoveable,  or  makes  a  movement  in  order  to  bring  its 
optic  axis  to  bear  upon  the  object.  In  the  latter  case,  we  know  at  once 
that  this  eye  had  before  deviated  from  the  object ;  thus,  if  it  moves 
downwards,  it  before  stood  too  high,  and  vice  versa. 

2.— PARALYSIS  OF  THE  EXTERNAL  RECTUS  MUSCLE  (OF 
THE  LEFT  EYE). 

If  the  object  (a  lighted  candle)  is  held  in  the  horizontal  meridian- 
plane  about  four  or  five  feet  in  front  of  the  patient,  we  find  that  both 
optic  axes  are  steadily  fixed  upon  it,  for  upon  the  closure  of  either  eye 


554  AFFECTIONS   OF   THE   MUSCLES   OF   THE   EYE. 

the  other  makes  no  movement.  The  object  is  then  successively  moved 
to  the  right  of  the  patient,  then  upwards  and  downwards,  and  still  both 
eyes  follow  it  accurately.  But  when  it  is  moved  somewhat  to  the  left  side 
of  the  median  line,  we  find  that  the  left  eye  lags  behind,  thus  giving 
rise  to  a  convergent  squint,  which  increases  in  proportion  as  the  object 
is  moved  further  to  the  left.  As  the  paralysis  of  a  muscle  only  shows 
itself  when  the  eye  is  moved  in  a  direction  which  calls  into  action  the 
muscle  in  question,  the  paralysis  of  the  left  external  rectus  does  not 
become  manifest  until  the  eye  has  to  be  moved  in  a  direction  to  the 
left  of  the  median  line. 

In  a  recent  case  of  complete  paralysis  of  the  external  rectus,  it  will 
be  found  that  Avhen  the  healthy  eye  is  closed,  and  the  object  moved 
slightly  into  the  left  half  of  the  field  of  vision,  the  left  eye  will  attempt 
to  follow  it,  not,  however,  in  a  straight,  horizontal  direction,  but  by  a 
zig-zag,  rotatory  movement,  brought  about  by  the  action  of  the  superior 
and  inferior  oblique. 

A  third  symptom  is,  that  the  secondary  deviation  is  considerably 
greater  than  the  primary.*  This  is  a  symptom  of  great  importance  in 
distinguishing  the  paralytic  from  the  common  concomitant  squint.  The 
deviation  of  the  squinting  eye  is  termed  the  j^rimary  deviation.  Now 
if  the  healthy  eye  is  covered,  the  other  will  move  in  a  certain  direction 
to  adjust  its  optic  axis  upon  the  object,  which  movement  will  be  accom- 
panied by  an  associated  movement  of  the  healthy,  covered  eye,  which 
thus  becomes  the  squinting  eye,  and  this  movement  of  the  healthy  eye 
is  termed  the  second  art/  deviation. 

To  render  this  more  intelligible,  let  us  presume  that  in  our  supposed 
case  of  paralysis  of  the  left  external  rectus,  the  object  is  moved  some- 
what to  the  left  side  of  the  patient.  At  a  certain  point,  a  slight  degree 
(say  one  line)  of  convergent  squint  of  the  left  eye  will  appear,  owing  to 
the  inability  of  this  eye  to  follow  the  object.  If  we  now  cover  the  right 
eye  with  our  hand,  the  left  will  make  an  outward  movement  of  one  line 
in  order  to  direct  its  optic  axis  upon  the  object,  but  the  right  eye  will 
simultaneously  make  an  associated  movement  inwards  of  perhaps  two- 
and-a-half  to  three  lines.  This  secondary  deviation  (two-and-a-half  to 
three  lines)  is  therefore  considerably  greater  than  the  primary  (one 
line).  The  reason  of  this  is  easily  explained.  As  the  external  rectus 
of  the  left  eye  is  insufficiently  innervated,  it  demands  a  greater  impulse 
of  the  will  to  bring  about  this  movement  of  one  line,  than  if  the  inner- 
vation were  normal.  But  this  increased  impulse  also  affects  the  asso- 
ciated, healthy,  internal  rectus  of  the  right  eye,  and   thus  produces  a 

*  To  watch  tlie  position  of  the  eje  excluded  from  participation  in  the  act  of 
vision,  a  slip  of  slightly  frosted  glass  should  be  placed  before  the  one  eje,  instead  of 
coTcring  it  with  the  hand  ;  for  whilst  this  prevents  the  patient  from  seeing,  it  does 
not  prevent  our  observing  the  position  of  the  eye. 


PARALYSIS  OF  THE  EXTERXAL  RECTUS  MUSCLE. 


Fig.  76. 


greater  amount  of  movement  in  this  eje.  Hence,  it  is  an  invariable 
rule  in  all  cases  of  paralysis,  that  the  secondary  deviation  considerably 
exceeds  the  primary,  whereas,  in  the  common  concomitant  squint  the 
two  are  exactly  equal. 

The  linear  measurement  of  a  squint  may  be  made  as  follows  : — We 
note  a  spot  upon  the  lower  eyelid,  which  would  correspond  to  an 
imaginary  vertical  line  drawn  through  the  centre  of  the  pupil  of  the 
squinting  eye,  when  the  other  eye  is  fixed  upon  an  object  held  at  from  8" 
to  12"  distance.  The  normal  eye  is  then  closed,  and  the  squinting  eye 
directed  upon  the  object,  and  the  spot  on  the  lower  lid  which  now  cor- 
responds to  a  vertical  line  drawn  through  the  centre  of  the  pupil  is 
again  noted,  and  the  distance  between  the  first  and  second  spot  gives 
the  linear  size  of  the  squint.  These  spots  may  be  at  first  marked 
with  a  dot  of  ink  upon  the  lower  lid, 
but  a  little  practice  will  soon  enable  us 
quickly  and  accurately  to  estimate  the 
distance  between  them.  This  proceeding 
is  illustrated  in  Fig.  70.  A  represents  the 
mark  corresponding  to  the  centre  of  the 
pupil  when  the  eye  is  squinting,  B  the 
mark  corresponding  to  the  centre  of  the 
pupil  when  the  eye  is  fixed  upon  the  ob- 
ject. The  distance  between  A  and  B  gives 
the  size  of  the  squint. 

It  is,  however,  still  more  convenient 
to  employ  Mr.  Laurence's  strabismometer 
(Fig.  77),  which  consists  of  an  ivory  plate 
(P)  moulded  to  the  conformation  of  the 
lower  eyelid.  Its  border  is  graduated 
in  such  a  manner,  that  while  the  centre  is 
designated  0,  Paris  lines  and  half  lines  are 
marked  off  on  each  side  of  0.  The  handle 
(E)  is  attached  to  the  plate.  The  plate  is 
applied  to  the  border  of  the  lower  eyelid 
of  the  squinting  eye,  and  the  size  of  the 
squint  can  be  read  off  with  great  ease  and 
accuracy. 

Another  symptom  which  is  at  once 
characteristic  of  a  paralytic  afiection,  is 
the  erroneous  projection  of  the  visual 
field.  For  instance,  if  we  close  the  right 
eye  and  tell  the  patient  to  strike  quickly 
with  his  finger  (if  he  does  it  slowly  he  Avill 
have  time  to  correct  his  mistake)   at  an 


556       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

object  held  somewhat  towards  the  left  of  the  median  line,  he  will 
miss  hitting  it,  by  going  too  much  to  the  left  side  of  it.  The  reason  of 
this  is,  that  the  insufficiently  innervated  external  rectus  requires  to  make 
a  contraction  far  exceeding  the  extent  of  the  required  movement,  and 
far  greater  than  would  be  necessary  if  the  innervation  were  normal. 
In  consequence  of  this,  the  patient  over-estimates  the  amount  of  move- 
ment, and  believes  the  object  to  lie  further  to  the  side  of  the  affected 
muscle  than  it  really  does,  and  consequently  strikes  too  much  to  the 
left.  If  the  paralytic  affection  is  not  too  complicated,  the  patients  in 
time  learn  to  correct  these  errors  of  projection.  The  dizziness  which 
they  often  complain  of  is  not  necessarily  due  to  a  cerebral  lesion,  but 
is  generally  owing  to  the  confusion  which  arises  from  the  diplopia,  etc. 

The  manner  of  examining  the  position  of  double  images,  and  the 
action  and  uses  of  prismatic  glasses,  have  been  explained  in  the  intro- 
ductory chapter,  p.  9. 

In  a  case  of  paralysis  of  the  external  rectus,  the  diplopia  will  appear 
when  the  object  is  moved  into  the  left  half  of  the  visual  field,  but  will 
be  absent  in  the  right  half.  The  distance  between  the  double  images  will 
increase  the  further  the  object  is  moved  to  the  left.  The  double  images 
show  only  lateral  differences,  being  parallel,  of  the  same  height,  and 
homonymous.  It  is,  however,  an  interesting  fact,  that  although  the 
external  rectus  has  no  direct  influence  upon  the  vertical  meridian,  it  yet, 
by  assisting  in  the  external  diagonal  positions  of  the  eyeball,  helps  in 
preserving  the  paralleHsm  of  the  vertical  meridians  of  the  two  eyes. 
For  instance,  if  the  patient  be  directed  to  look  at  an  object  held  diago- 
nally upwards  to  the  left,  the  right  eye  will  be  moved  into  the  necessary 
position  by  the  combined  action  of  the  superior  rectus,  inferior  oblique 
and  the  internal  rectus,  its  vertical  meridian  being  inclined  to  the  left. 
The  left  eye  requires,  in  order  to  be  moved  upwards  and  outwards,  the 
combined  action  of  the  superior  rectus,  the  inferior  oblique,  and  the 
external  rectus.  But  as  the  latter  is  paralysed,  the  left  eye  will  remain 
almost  straight,  and  its  vertical  meridian  vertical  (instead  of  being 
inclined  towards  the  left),  the  parallelism  of  the  vertical  meridians  is 
therefore  destroyed,  and  they  convei'ge  at  the  top,  whilst  the  double 
images  appear  to  .the  patient  to  diverge  at  the  top.  But  as  in  con- 
formity with  the  laws  of  normal  vision,  the  image  which  falls  in  the 
slanting  meridian  of  the  healthy  right  eye  appears  straight  to  the 
patient,  the  image  of  the  affected  eye  will  necessarily  appear  slanting. 

Hence,  in  the  diagonal  positions  to  the  left,  viz.,  upwards  and  out- 
wards, and  downwards  and  outwards,  the  double  images  will  show  not 
only  a  difference  in  inclination,  but  also  in  height.  As  the  external 
rectus  is  engaged,  together  with  the  superior  rectus  and  inferior  oblique, 
in  bringing  about  the  movement  of  the  eye  diagonally  upwards  and  out- 
wards, its  paralysis  must  impair  this,  and  also  affect  the  position  of  the 


PARALYSIS  OF  THE  EXTERNAL  RECTUS  MUSCLE. 


557 


vertical  meridian,  wliicli,  instead  of  being  parallel  with  tliat  of  the  right 
eye,  and  inclined  to  the  left,  will  be  nearly  vertical,  and  consequently 
the  two  vertical  meridians  Avill  converge  at  the  top,  the  double  images 
appearing  to  the  patient  to  diverge.  A  glance  at  Fig.  78  will  readily 
explain  this. 

In  Fig.  78,  I  represents  the  healthy  right  eye,  whose  vertical 
meridian  A  B  is  vertical,  and  whose  horizontal  meridian  G  D  is  hori- 
zontal, the  image  a  b  falls  in  the  vertical  meridian.  II  is  the  left  eye 
affected  with  paralysis  of  the  external  rectus,  in  the  position  upwards 

Fiff.  78. 


IV. 


and  outwards  the  vertical  meridian  A'  B'  is  not  parallel  to  that  of  the 
right  eye,  but  converges  towards  it  (^A"  B").  The  image  a'  h'  will  con- 
sequently not  fall  in  the  vertical  meridian,  but  in  the  upper  and  outer 
{A"  D"),  and  the  inner  and  lower  (G"  B")  quadrants  of  the  retina. 
The  double  image  will,  therefore,  appear  to  patient  to  be  turned  to- 
wards the  left,  and  to  diverge  at  the  top  from  that  of  the  right  eye 
(III  and  IV,  a  h  and  a  I'). 

I  must  here  again  call  attention  to  the  fact  that  the  inclinations  of  the 
vertical  meridians  are  merely  relative ;  so  that,  although  in  reality  the 
image  of  the  healthy  eye  may  be  the  one  which  is  inclined,  it  generally 
appears  to  the  patient  to  be  straight,  and  the  image  of  the  affected  eye 
is  the  one  which  seems  to  be  slanting,  although  its  vertical  meridian 
may  remain  vertical. 


558 


AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 


We  also  meet  with  a  curious  phenomenon  in  this  movement 
(upwards  and  outwards),  viz.,  a  difference  in  the  height  of  the  double 
images,  without  any  difference  in  the  height  of  the  cornea.  This  appa- 
rent anomaly  is  easily  explained  by  a  glance  at  Fig.  79.  In  I  the 
rays  from  the  object  will  fall  on  the  yellow  spot  a,  but  in  the  left  eye 


Fig.  79. 


(II),  on  account  of  the  convergence  of  the  eyes  and  the  inclination 
inwards  of  the  vertical  meridian  (A'  B'),  the  rays  will  not  fall  upon  a, 
but  on  a",  a  point  in  the  inner  and  upper  quadrant  of  the  retina,  and 
hence  the  double  image  will  lie  to  the  left  side,  and  below  the  object. 
Whereas,  in  the  diagonal  position  downwards  and  outwards,  the  double 
image  will  lie  to  the  left  and  above  the  object,  and  be  inchned  towards 
the  right. 

The  position  of  the  head  is  also  characteristic,  for  the  patient 
carries  it  turned  slightly  to  the  left,  in  order  to  avoid  the  diplopia,  by 
bringing  all  objects  as  much  as  possible  into  the  right  half  of  the 
field  of  vision. 

The  prognosis  is  genei'ally  favourable  if  the  paralysis  of  the  external 
rectus  muscle  is  acute,  not  too  considerable  in  extent,  and  not  depen- 
dent upon  a  cerebral  lesion.  Such  cases  are  often  completely  cured,  or 
very  greatly  relieved.  Sometimes,  however,  secondary  contraction  of 
the  internal  rectus  of  the  same  eye  supervenes,  on  account  of  the 
diminished  force  opposed  to  the  action  of  the  latter  muscle.  In  this 
way,  a  permanent  convergent  squint  of  this  eye  may  be  produced.  But 
if  the  affected  eye  enjoys  the  better  sight  of  the  two,  and  is  only  suffering 
from  a  partial  paralysis  of  the  external  rectus,  the  patient  may  use  it,  in 
spite  of  the  effort  required,  in  preference  to  the  other,  which  will  squint 
considerably  inwards,  and  perhaps  permanently  so. 

In  paralysis  of  the  external  rectus,  a  prism  would  have  to  be  applied 
with  its  base  to  the  temple,  so  that  the  rays  may  be  refracted  outwards  ; 
for,  on  account  of  the  convergence  of  the  optic  axis,  the  rays  from  the 
object  will  fall  to  the  inner  side  of  the  yellow  spot.  Prismatic  glasses 
may  be  used  for  two  pm-poses :   1,  simply  to  free  the  patient  from  the 


PARALYSIS   OF   THE   THIRD   NERVE.  ooi) 

anuoyauce  of  diplopia ;  2,  for  the  purpose  of  sliglitly  exercising  the 
paralysed  muscle,  and  so  gradually  strengthening  it.  In  the  former  case, 
we  prescribe  that  number  of  prism  which  completely  neutralizes  the 
diplopia  at  a  certain  distance.  Whereas,  if  we  desire  to  exercise  the 
affected  muscle,  we  order  a  prism  which  only  approximates  the  double 
images  ;  this  proves  very  confusing  to  the  patient,  and  he  endeavours, 
if  possible,  to  fuse  them  into  one  by  a  voluntary  exertion  of  the 
paralysed  muscle.  In  doing  this,  care  must  be  taken  that  the  prism  is 
not  too  weak  ;  at  first  one  should  be  selected  which  nearly  fuses  the 
double  images,  and  then,  as  the  muscle  becomes  stronger,  a  gradually 
weaker  prism  may  be  prescribed. 


3.— PARALYSIS  OF  THE  THIRD  NERVE. 

The  third  is  the  principal  motor  nerve  of  the  eyeball ;  it  divides  in 
the  orbit  into  two  branches,  an  upper  and  a  lower.  The  former  supplies 
the  superior  rectus  and  the  levator  palpebras  superioris  ;  the  latter,  the 
internal  recius,  inferior  rectus,  inferior  oblique,  sphincter  pupillae,  and 
ciliary  muscle.  According  to  Volkmann  and  Ftisebeck,  the  third 
also  sends  a  small  branchlet  to  the  superior  oblique  and  external 
rectus. 

The  paralysis  of  the  third  nerve  may  vary  in  degree  and  extent,  and 
may  be  complete  or  partial.  1.  All  the  muscles  supplied  by  it  may  be 
more  or  less  implicated  ;  they  may  be  all  completely  or  all  partially 
paralysed  ;  or,  again,  some  may  be  completely  paralysed,  whilst  the  rest 
are  only  partially  affected.  2.  One  or  more  muscles  may  be  completely 
or  partially  paralysed,  the  rest  being  unaffected. 

Before  describing  the  symptoms  presented  by  the  isolated  paralysis 
of  the  individual  muscles  supplied  by  the  third  nerve,  it  will  be  well  to 
glance  at  those  which  are  caused  by  a  paralysis  of  all  the  branches  of 
the  nerve. 

Let  us,  therefore,  suppose  the  existence  of  a  complete  paralysis  of 
the  third  nerve  of  the  left  eye.  The  following  would  be  the  symptoms 
present  in  such  a  case  : — The  upper  eyelid  hangs  down  over  the  eye  ; 
upon  lifting  it  and  moving  an  object  in  different  directions,  we  find  that 
the  eye  fails  to  follow  it  in  the  upward,  inward,  and  downward  du-ec- 
tion.  It  can  still,  however,  move  outwards  by  the  action  -of  the 
external  rectus,  and  somewhat  downwards  and  outwards  by  aid  of  the 
superior  oblique.  Generally,  secondary  contraction  of  the  external 
rectus  soon  supervenes,  and  a  marked  divergent  squint  arises,  accom- 
panied by  crossed  diplopia. 

If  we  move  the  object  over  to  the  right  of  the  patient,  a  divergent 
squint  arises  (with  crossed  diplopia),  which  increases  in  proportion  as 


560       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

the  object  is  moved  farther  in  this  direction.  Upon  moving  tlic  object 
upwards,  the  right  eye  will  follow  it,  but  the  left  will  lag  behind,  the 
rays  from  the  object  will  therefore  fall  upon  a  portion  of  the  retina 
below  the  yellow  spot,  and  the  double  image  be  projected  above  that  of 
the  right  eye.  If  the  object  is  moved  downwards,  the  reverse  will  of 
course  obtain,  and  the  image  of  the  left  eye  be  projected  beneath  that 
of  the  I'ight. 

On  account  of  the  paralysis  of  the  branch  to  the  sphincter  pupillae, 
the  pupil  will  be  somewhat  dilated  (about  2  or  2^  lines  in  diameter), 
and  immoveable.  The  paralysis  of  this  branch  may,  however,  precede 
that  of  general  paralysis  of  the  third  nerve.  Upon  the  application  of 
atropine,  the  pupil  dilates  to  its  fullest  extent.  Finally,  as  the  ciliary 
muscle  is  paralysed,  the  eye  will  have  lost  its  power  of  accommoda- 
tion. 

If  the  healthy  eye  is  closed,  and  the  patient  directed  to  walk  straight 
up  to  a  certain  object,  he  becomes  giddy  and  faint,  and  reels  in  his  gait ; 
which  is  owing  to  the  illusion  which  exists  in  his  mind  between  the  real 
and  imaginary  position  of  the  object.  There  is  generally  some  protru- 
sion of  the  eyeball,  on  account  of  the  paralysis  of  the  three  recti 
muscles,  whose  office  it  is  to  pull  the  eye  into  the  orbit.*  There  is  also 
marked  ptosis,  but  the  latter  is  not  so  excessive  as  when  the  orbicularis 
pelpebrarum  is  also  paralysed.  By  relaxing  the  orbicularis  and  con- 
tracting the  fi^ontalis,  the  upper  eyelid  can  still  be  somewhat  lifted. 
Although  we  but  seldom  meet  with  a  complete,  isolated  paralysis  of  the 
individual  muscles  supplied  by  the  third  nerve,  it  wiU  be  well  briefly  to 
consider  the  symptoms  which  paralysis  of  these  different  muscles  would 
present. 

4.— PARALYSIS  OF  THE  INTERN'AL  RECTUS  OF  THE  LEFT 

EYE. 

"When  an  object  is  moved  from  the  left  to  the  right  side,  both  eyes 
will  be  fixed  upon  it  nearly  up  to  the  middle  line,  but  when  it  is  carried 
over  to  the  right,  the  left  eye  will  lag  more  and  more  behind,  thus 
giving  rise  to  a  divergent  squint.  If  the  paralysis  is  complete,  and  the 
patient  endeavours  to  move  his  left  eye  inwards,  a  vicarious,  rotatory, 
zig-zag  movement  inwards  will  be  produced  by  the  action  of  the 
superior  and  inferior  recti.     As  the  squint  is  divergent,  the  diplopia  is 

*  H.  Miiller  discovered  in  Uie  inferior  orbital  fissure  a  reddish  grey  mass,  con- 
sisting of  bundles  of  unstriped  muscular  fibre  with  elastic  tendons,  analogous  to  the 
orbital  membrane  of  the  mammalia.  He  supposed  that  its  action  is  to  protrude  the 
eyeball ;  it  is  supplied  by  fibres  from  the  sympathetic,  and  irritation  of  the  latter  iu 
the  neck  has  been  found  to  cause  protrusion  of  the  eye,  perhaps  through  the  action 
of  this  muscle. 


PARALYSIS  OF  THE  SUPERIOR  RECTUS  OF  THE  LEFT  EYE.   561 

crossed,  and  the  lateral  distance  between  the  double  images  will 
increase  in  proportion  as  the  object  is  carried  over  to  the  right,  but 
there  will  be  no  difference  in  the  height  and  straightness  of  the  images 
in  looking  vertically  upwards  or  downwards.  But  in  the  diagonal 
positions  inwards,  there  will  not  only  be  a  difference  in  the  height  of 
the  double  images,  but  the  one  will  slant  considerably.  In  the  oblique 
position  of  the  object  upwards  and  inwards,  the  double  images  will 
diverge  at  the  top,  that  of  the  left  eye  being  inclined  to  the  right. 
Whereas,  in  the  diagonal  position  downwards  and  inwards,  the  double 
images  appear  to  converge  at  the  top,  that  of  the  left  eye  being  inclined 
towards  the  left. 

In  the  diagonal  positions  inwards,  there  will  also  be  a  difference  in 
the  height  of  the  images,  even  although  there  is  no  difference  in  the 
height  of  the  cornea.  The  reason  of  this  has  been  already  explained 
in  the  description  of  paralysis  of  the  external  rectus  muscle. 

The  Line  wliich  divides  the  portion  of  the  field  in  which  the  patient 
sees  double  from  that  in  which  single  vision  exists,  docs  not  run 
vertically  from  above  doAvnwards,  but  obliquely  from  left  to  right ;  lying 
to  the  left  side  of  the  vertical  line  above  the  horizontal  line,  and  to  the 
right  side  of  it  below  the  horizontal  line.  This  is  explained  by  the  fact 
that  the  divergence  is  much  greater  when  the  eyes  look  upwards,  than 
when  they  look  do-\vn. 

The  patient's  head  is  turned  towards  the  right,  so  as  to  avoid  di- 
plopia, by  briaging  objects  as  much  as  possible  into  the  left  half  of  the 
visual  field. 


5.— PARALYSIS  OF  THE  SUPERIOR  RECTUS  OF  THE 
LEFT  EYE. 

This  muscle  moves  the  eye  upwards  and  inwards,  and  inchnes  the 
vertical  meridian  inwards. 

The  ineflSciency  of  the  paralysed  superior  rectus  will  not  be  apparent 
in  the  movements  of  the  eye  below  the  horizontal  diameter,  but  only  in 
those  above  the  latter.  The  diplopia  will  consequently  be  also  only 
apparent  in  the  upper  half  of  the  field.  When  the  object  is  moved 
above  the  hoi-izontal  line,  the  left  eye  will  lag  behind,  and  this  deviation 
will  increase  in  proportion  the  higher  the  object  is  moved.  At  the  same 
time  there  will  also  be  a  divergent  squint,  for  on  account  of  the  paralysis 
of  the  superior  rectus,  the  inferior  oblique  will  move  the  eye  somewhat 
outwards.  If  the  right  eye  is  covered,  and  the  patient  directed  to  look 
■\vith  the  left  at  an  object  held  slightly  in  the  upper  half  of  the  visual 
field,  the  left  eye  will  move  upwards  and  inwards  (the  degree  depend- 
ing upon  the  amount  of  paralysis),  showing  that  it  had  before  deviated 

2  0 


502       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

downwards  and  outwards.  The  covered  eye  will  at  the  same  time  make 
a  considerably  greater  associated  movement  upwards  and  outwards. 
The  patient  in  endeavouring  to  strike  an  object  will  aim  too  high.  He 
will  carry  his  head  thrown  back,  so  as  to  bring  all  objects,  as  much  as 
possible,  into  the  lower  half  of  the  field. 

The  diplopia  manifests  itself  in  the  upper  half  of  the  visual  field. 
The  double  images  show  lateral  differences,  are  crossed,  different  in 
height,  and  not  parallel. 

As  the  cornea  deviates  downwards  and  outwards,  the  rays  from  an 
object  held  above  the  horizontal  meridian  line  fall  upon  an  outer  and 
lower  portion  of  the  retina,  and  will  consequently  be  projected  upwards 
and  inwards ;  the  double  image  of  the  affected  eye  (pseudo-image) 
lying  above  and  to  the  right  of  the  image  of  the  right  eye. 

As  the  action  of  the  superior  rectus  upon  the  height  of  the  eye 
increases  as  the  latter  is  moved  outwards  (to  the  left),  the  ineflBciency 
of  the  paralysed  muscle  in  raising  the  cornea,  will  also  be  most  evident 
in  this  direction.  The  difference  in  the  height  of  the  double  images, 
therefore,  increases  as  the  eye  is  turned  outwards,  and  diminishes  as  it 
is  turned  inwards.  On  the  other  hand,  the  inclination  of  the  vertical 
meridian  will  be  most  apparent  when  the  eye  is  turned  inwards,  and 
least  so  when  it  is  turned  outwards  (to  the  left).  On  account  of  the 
paralysis  of  the  superior  rectus,  the  vertical  meridians  are  not  parallel, 
but  that  of  the  left  eye  is  turned  outwards  by  the  unopposed  action  of 
the  inferior  oblique.  Hence  the  pseudo-image  would  appear  to  con- 
verge towards  the  image  of  the  right  eye,  but  the  double  images  are 
crossed,  and  hence  they  diverge  at  the  top,  the  pseudo-image  being 
inclined  towards  the  right.* 


C— THE  PARALYSIS  OF  THE  INFERIOR  RECTUS  OF  THE 

LEFT  EYE. 

The  symptoms  arising  in  a  paralysis  of  tliis  muscle  are  just  the 
reverse  of  those  in  paralysis  of  the  superior  rectus.  The  want  of 
movement  and  consequent  diplopia  are  only  apparent  when  the  object 
is  held  below  the  horizontal  meridian  line.  The  pseudo-image  lies 
above  that  of  the  right  eye,  and  towards  its  right.  The  double  images 
increase  in  height  when  the  eyes  are  moved  to  the  left,  and  in  inclina- 
tion when  they  are  moved  to  the  right.  The  double  images  are  crossed 
and  the  pseudo-image  inclined  towards  that  of  the  right  eye  (i.e., 
inclined  towards  the  left). 

*  As  patients  often  find  it  diflicult  to  estimate  accurately  the  obliquity  of  a 
small  object,  such  as  the  flame  of  a  lighted  candle,  it  is  better  to  use  as  an  object, 
a  while  staff,  or  a  roll  of  paper  about  12  inches  in  length. 


I 


PAKALYSIb  OF  THE  SUPERIOR  OBLIQUE  OE  THE  LEFT  EYE.   5Go 


7.— PARALYSIS  OF  THE  INFERIOR  OBLIQUE  OF  THE 
LEFT  EYE. 

As  it  is  extremely  doubtful  whether  an  isolated  paralysis  of  this 
muscle  ever  occurs,  I  shall  not  describe  the  sjrmptoms  which  would  be 
presented  by  such  an  affection,  but  simply  state  that  they  would  be 
just  the  reverse  of  those  met  with  in  paralysis  of  the  superior  oblique, 
and  from  a  knowledge  of  which  these  symptoms  could  easily  be 
constructed. 


8.— PARALYSIS  OF  THE  SUPERIOR  OBLIQUE  OF  THE 
LEFT  EYE,  ETC. 

The  paralysis  of  the  superior  oblique  illustrates  better  than  that  of 
any  other  of  the  ocular  muscles,  the  correctness  of  the  rules  laid  down 
as  to  action  of  the  different  muscles,  and  the  nature  of  the  diplopia 
presented  by  their  paralysis.  Indeed,  the  deviation  of  the  optic  axis  is 
so  extremely  slight  in  cases  of  paralysis  of  the  superior  oblique,  that  it 
might  easily  escape  detection,  and  we  must,  therefore,  place  our  chief 
reliance  upon  the  position  of  the  double  images  to  assist  us  in  determin- 
ing the  diagnosis. 

A  person  ajQTected  with  paralysis  of  the  left  superior  oblique  would 
complain  that  objects  (the  floor,  steps,  etc.)  in  the  lower  half  of  the  field 
appear  double  and  irregular  in  outline.  Above  the  horizontal  median 
Une,  both  optic  axes  are  fixed  upon  the  object  and  no  diplopia  exists. 
If  the  object  is  held  in  the  horizontal  median  line  or  a  very  little  below 
it,  a  very  slight  deviation  of  the  left  eye  in  an  upward  and  inward 
direction  is  noticed,  which  becomes  more  and  more  marked  the  further 
the  object  is  moved  into  the"  lower  half  of  the  field,  more  especially 
towards  the  right.  If  the  right  eye  is  closed,  the  left  makes  a  well- 
marked  movement  downwards  and  outwards,  and  there  will  be  an 
erroneous  projection  of  the  visual  field  in  the  same  direction.  Upon 
closing  the  healthy  right  eye,  an:l  testing  the  mobility  of  the  left,  we 
m.ight  at  first  suppose  it  to  be  unimpaired  in  all  directions,  but  on 
closer  examination  we  find  that  downwards  and  inwards  (towards  the 
nose)  there  is  a  distinct  want  of  mobility.  Instead  of  following  the 
circular  sweep  of  the  object  from  below  to  the  inner  side,  the  optic 
axis  makes  a  diagonal  spring  upwards  and  inwards.  The  double 
images  are  homonymous,  and  show  a  difference  both  in  height  and 
laterally,  and  the  one  slants.  The  diplopia  is  confined  to  the  lower 
half  of  the  visual  field,  and  is  absent  in  the  upper.  On  account  of  the 
convergent  squint  which  arises  below  the  horizontal  line,  the  diplopia 

2  0  2 


564       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

is  homonymous,  and  as  tlie  left  eye  remains  at  the  same  time  too  high, 
its  double  image  will  appear  beneath  that  of  the  right  eye.  The  lateral 
difference  between  the  double  images  increases  the  more,  the  further 
the  object  is  moved  downwards,  as  the  convergence  of  the  optic  axes 
then  becomes  greater,  on  account  of  the  unopposed  action  of  the  inferior 
rectus.  The  difference  in  the  height  of  the  double  images  increases  the 
m.ore,  the  further  the  object  is  moved  over  to  the  right,  and  diminishes 
as  it  is  moved  over  to  the  left.  This  is  owing  to  the  fact,  that  the 
superior  oblique  exerts  the  greatest  influence  upon  the  height  of  the  eye- 
ball when  the  eye  is  moved  downwards  and  inwards,  and  hence  its  loss 
of  power  upon  the  height  of  the  cornea  will  also  be  felt  the  most  in  this 
direction.  On  the  other  hand,  the  inclination  of  the  double  images  will 
be  greatest  when  the  object  is  moved  over  to  the  left,  and  least  when  it  is 
carried  over  to  the  right.  For  the  superior  oblique  exerts  most  influence 
on  the  position  of  the  vertical  meridian,  when  the  eye  is  moved  down- 
wards and  outwards.  On  account  of  the  paralysis  of  the  superior 
oblique,  the  inferior  rectus  will  exercise  unopposed  sway  over  the  vertical 
naeridian  in  all  the  movements  of  the  eye  below  the  horizontal  median 
line,  and  incline  it  outwards.  The  parallelism  of  the  vertical  meridians 
will,  therefore,  be  destroyed,  and  they  will  diverge  at  the  top,  the  double 
images  appearing  to  converge.  For  on  account  of  the  slanting  outwards 
of  the  vertical  meridian  of  the  left  eye,  the  image  from  the  object 
will  not  fall  in  the  vertical  meridian,  but  upon  the  upper  and  inner  and 
lower  and  outer  quadrants  of  the  retina,  and  the  pseudo-image  will, 
therefore,  appear  to  the  patient  to  be  inclined  towards  the  right,  and  to 
converge  towards  the  image  of  the  right  eye.  A  glance  at  Fig.  78, 
p.  557,  will  render  this  intelligible,  it  being  remembered,  however,  that 
the  vertical  meridian  is  turned  outwards  in  paralysis  of  the  superior 
oblique,  and  inwards  in  that  of  the  external  rectus. 

When  the  object  is  carried  very  far  down  into  the  lower  half  of  the 
field,  a  cui'ious  phenomenon  is  observed,  viz.,  that  the  pseudo-image 
appears  above  that  of  the  right  eye,  even  although  the  left  cornea  still 
remains  higher  than  the  right.  This  is  due  to  the  extreme  inclination 
of  the  vertical  meridian,  which  becomes  so  great  when  the  eye  is  moved 
far  downwards,  that  a  dislocation  of  the  quadrants  of  the  retina  takes 
place,  the  rays  from  the  object  falling  no  longer  upon  the  inner  and 
upper  quadrant  of  the  retina,  but  upon  the  inner  and  lower,  and  they 
are  hence  projected  upwards  and  to  the  left. 

The  double  images  in  paralysis  of  the  superior  oblique  are  not 
at  the  same  distance  from  the  patient,  but  that  of  the  affected  eye  is 
considerably  nearer  to  him.  This  was  I  believe  first  noticed  by 
Dr.  Michaelis.  It  would  appear  to  be  due  to  the  projection  of  the 
image  upon  a  horizontal  sui'face  below  the  eyes  (e.g.,  the  floor  of  the 


PARALYSIS  OF  THE  SUPERIOR  OBLIQUE  OF  THE  LEFT  EYE.   5(55 

room),  for  this  symptom  disajopears  with  an  alteration  of  the  surface 
of  projection.* 

The  line  which  divides  the  field  of  single  from  that  of  double  vision 
does  not  run  horizontal,  but  obliquely  downwards  from  the  right  to 
the  left.  The  patient  carries  his  head  turned  downwards  and  to 
the  right,  so  as  to  bring  the  objects  as  much  as  possible  into  the  upper 
and  left  portion  of  the  field,  as  the  diplopia  arises  sooner  in  the  right 
half.  Prisms  must  be  turned  with  their  base  downwards  and  out- 
wards. 

After  a  paralysis  of  the  superior  oblique  has  existed  for  some  time, 
secondary  contraction  of  the  inferior  oblique  often  supervenes.  The 
diplopia  then  extends  into  the  upper  half  of  the  visual  field,  but 
here  becomes  crossed,  the  pseudo-image,  however,  being  still  beneath 
that  of  the  right  eye.  This  is  due  to  the  cornea  being  moved  abnormally 
upwards  and  outvi'ards,  on  account  of  the  contraction  of  the  inferior 
oblique.  The  increase  in  the  height  of  the  double  images  will  augment 
towards  the  right,  and  diminish  towards  the  left ;  the  reverse  obtaining 
with  reg^ai'd  to  the  inclination  of  the  double  images. 


Having  considered  the  various  symptoms  presented  by  the  paralytic 
affections  of  the  different  muscles  of  the  eye,  we  must  now  turn  our 
attention  to  their  causes,  prognosis,  and  treatment. 

We  may  distinguish  peripheral  and  cerebral  causes.  Amongst 
the  former,  cold  and  rheumatism  are  the  most  frequent.  In  such 
cases,  the  affection  is  rapidly  developed,  and  is  generally  accom- 
panied by  more  or  less  severe  rheumatic  pains  in  the  corresponding 
side  of  the  face  and  head.  Very  frequently  there  is  no  difiiculty  in 
tracing  the  cause  to  a  cold  which  the  patient  has  caught  from  a  sudden 
exposure  to  a  great  change  in  temperature,  or  to  a  draught  of  cold 
wind.  This  is  soon  followed  by  pain  in  and  around  the  orbit,  accom- 
panied by  a  slight  degree  of  diplopia.  The  pathological  changes  in 
such,  cases  generally  consist  in  a  rheumatic  inflammation  of  the  nerve 
sheath. 

The  causes  may  be  situated  in  the  orbit.  Amongst  these  we  must 
enumerate  effusions  of  blood,  all  the  different  forms  of  orbital  tumour, 
abscess  of  the  orbit,  exophthalmic  goitre,  etc. 

The  most  frequent  cause  is,  however,  syphilis.  According  to 
Von  Graefe  about  one-third  of  the  paralytic  affections  of  the  muscles 
of  the  eye  are  due  to  it.  In  many  cases  it  is,  however,  impossible  to 
determine  with  any  degree  of  accuracy  the  exact  seat  of  the  cause  • 
we  must  be  satisfied  with  the  fact,  that  the  patient  has  suffered  from 

*  "  Symptoracnlehre  der  Augenmuskclliilunungcn,"  A.  Yon  Graefe,  1867,  p.  145. 


566  AFFECTIONS   OF   THE   MUSCLES   OF   THE   EYE. 

syphilis,   and  we  frequently  find  that  a  rapid  recovery  ensues  under 
proper  anti- syphilitic  treatment. 

Syphilitic  nodes  or  exostoses  may  be  situated  in  the  orbit,  or  at  the 
base  of  the  brain,  and  cause  the  paralysis  by  direct  pressure  upon  the 
nerve.     Syphilitic  neuromata  may  also  produce  it. 

Paralysis  of  the  ocular  muscles  is  often  due  to  some  cause  situated 
at  the  'base  of  the  skull,  and  this  must  be  especially  suspected  if  several 
muscles  of  one  or  of  both  eyes  are  affected,  or  if  some  other  nerves 
(such  as  the  facial  or  some  branches  of  the  fifth)  are  also  impKcated. 
We  find  that  the  causes  situated  at  the  base  of  the  brain,  generally 
produce  paralysis  by  a  direct  compression  of  the  nerves  which  lie  at 
this  situation.  Amongst  such  causes,  we  must  especially  enumerate 
syphilitic  and  rheumatic  ostitis  and  periostitis,  exostoses,  syphilitic 
tophi,  tubercular  deposits,  efirisions  of  blood,  and  tumours  of  various 
kinds.  In  cases  of  tumour  or  aneurism,  the  progress  of  the  paralysis 
is  generally  slow,  whereas,  the  reverse  is  the  case  in  inflammatory 
exudations. 

The  cause  may,  however,  be  situated  in  the  brain  itself,  and  we  then 
generally  find  that  the  patient  shows  some  derangement  of  the  intellec- 
tual functions.  His  memory  fails  him,  and  he  experiences  a  difficulty  in 
arranging  his  ideas,  or  in  giving  expression  to  them.  These  derange- 
ments are  often  very  transitory,  and  may  vary  greatly  in  extent,  from 
a  slight  impairment  of  memory  to  a  state  bordering  on  idiocy.  Ptosis 
is  not  unfrequently  a  symptom  of  a  cerebral  afiection,  whereas  lagoph- 
thalmus  is  only  exceptionally  so.  Amongst  the  various  affections  within 
the  brain  which  may  produce  paralysis  of  the  muscles  of  the  eye,  must 
be  mentioned  softening  of  the  brain,  efi'usions  of  blood,  tubercular 
deposits,  aneurisms,  impermeability  of  some  of  the  cerebral  blood- 
vessels, tumours  situated  withia  the  brain,  hydrocephalus,  etc.  The 
nature  of  the  diplopia  aids  us  to  a  certain  extent  in  localising  the  cause 
of  the  paralysis,  for  in  paralysis  due  to  a  cerebral  lesion  we  observe  that 
there  is  great  difficulty  in  the  fusion  of  the  double  images.  It  is  found 
very  difficult,  or  almost  impossible  to  unite  them,  even  with  the  most 
carefully  selected  prism,  the  patient  being  unable  to  fuse  them  by  a 
voluntary  efibrt,  even  although  they  are  brought  very  close  together. 

The  prognosis  of  the  difierent  kinds  of  paralysis  varies  with  the 
cause,  the  degree,  and  the  length  of  duration  of  the  paralysis. 

With  regard  to  the  general  prognosis  of  paralytic  affections  of  the 
muscles  of  the  eye,  it  may  be  laid  down  as  a  rule  that  it  is  the  more 
favourable,  the  more  recent  the  afiection.  Again,  a  partial  paralysis 
affords  a  more  favourable  prognosis  than  if  it  is  complete,  even 
altliougli  the  latter  may  be  of  much  shorter  duration.  The  character 
of  the  diplopia  is  also  prognostically  of  importance,   for  the  double 


I 

I 


PARALYSIS  OF  THE  SITERIOR  OBLIQUE  OF  THE  LEFT  EYE.      5(57 

images  vvliicli  only  sliow  a  lateral  difference  and  none  in  height,  are  far 
more  easily  united  than  when  there  is  a  difference  in  height.  Slight 
cases  of  paralysis  of  the  internal  or  external  rectus  may  be  spon- 
taneously cured  by  the  effort  of  the  act  of  vision,  which  causes  the  fusion 
of  the  images. 

The  prognosis  is  generally  very  favourable  in  the  rheumatic  paralysis, 
especially  if  the  patient  applies  soon  after  the  outbreak  of  the  disease. 
If  the  cause  is  situated  within  the  orbit,  the  prognosis  will  principally 
depend  upon  the  fact  whether  the  cause  can  be  removed  or  dispelled. 

In  the  syphilitic  form  of  paralysis,  the  prognosis  leans  towards  the 
favourable  side  of  the  scale,  but  is  greatly  influenced  by  the  seat  and 
extent  of  the  cause.  In  the  central  causes  it  is,  however,  much  more 
unfavourable,  although  a  complete  cure  may  arise,  if  the  primary  affec- 
tion is  removed  (as  in  absorption  of  exudations,  etc.) 

The  treatment  must  also  vary  with  the  nature  of  the  cause.  In 
rheumatic  paralysis,  a  free  purge  should  be  administered,  and  diaphoretics 
be  prescribed,  together  with  a  good  sized  blister  behind  the  ear.  I  have 
found  the  greatest  benefit  from  the  latter  remedy,  as  also  from  the  use 
of  iodide  of  potassium  internally.  When  the  inflammatory  symptoms 
have  subsided,  and  the  nerves  are  regaining  some  power.  Faradization 
should  be  applied.  In  syphilitic  cases,  the  iodide  and  bromide  of  potas- 
sium are  found  of  the  greatest  service ;  or  mercurial  inunction  may  be 
employed,  if  necessary.  Zitmann's  decoction  is  also  very  serviceable, 
as  it  acts  not  only  as  an  anti- syphilitic,  but  also  as  a  diaphoretic.  Its 
use,  however,  entails  a  good  deal  of  inconvenience  and  discomfort. 

To  relieve  the  patient  of  the  annoyance  and  confusion  produced  by 
the  diplopia,  the  affected  eye  should  be  excluded  from  the  visual  act  by 
a  shade  or  a  piece  of  frosted  glass  (if  spectacles  are  used).  This  exclu- 
sion also  obviates  the  tendency  of  the  patient  to  carry  his  head  turned 
to  one  side. 

Prismatic  glasses  may  likewise  be  employed  for  the  p^^rpose  of 
fusing  the  double  images,  and  their  strength,  and  the  direction  in  which 
their  base  is  to  be  turned,  will  depend  upon  the  muscle  affected,  and  the 
degree  of  deviation.  In  paralysis  of  the  internal  rectus,  the  base  would 
be  turned  inwards,  in  that  of  the  external  rectus,  outwards.  If  the 
double  images  show  both  a  difference  sideways  and  in  height,  we  may 
divide  the  prisms,  placing  one  with  its  base  laterally,  and  the  other  with 
its  base  turned  upwards  or  downwards,  as  the  case  may  be.  Or  we 
may  divide  these  two  prisms  between  the  two  eyes.  In  accordance 
with  the  fact,  that  the  eye  can  readily  overcome  lateral  differences  in  the 
double  images,  whereas,  it  cannot  correct  any  but  the  very  slightest 
difference  in  height,  we  often  find  that  if  we  correct  the  latter  by  a 
prism,  the  lateral  differences  are  at  once  corrected  by  an  effort  of  one  of 


568       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

the  horizontal  muscles  of  the  eye.  This  fact  is  of  much  importance  in 
those  cases  in  which  we  operate  for  the  sake  of  curing  diplopia.  I  have 
already  stated,  when  speaking  of  paralysis  of  the  external  rectus,  that 
when  we  desire  to  use  prisms  therapeutically,  the  double  images  should 
be  not  fused  into  one,  but  only  approximated,  in  order  that  the  para- 
lysed muscle  may  be  stimulated  to  an  effort  to  unite  them. 

Electricity  is  often  found  of  great  service  in  the  treatment  of  para- 
lysis of  the  muscles  of  the  eye,  especially  if  the  cause  is  peripheral. 
Generally  one  pole  of  the  instrument  is  applied  to  the  closed  eyelid  in 
a  situation  corresponding  to  the  affected  muscle,  the  other  pole  being 
placed  on  the  temple  or  the  back  of  the  neck.  I  have  sometimes  gained 
very  successful  results  with  the  common  rotatory  machine,  keeping  up 
its  action  for  a  few  minutes.  Hitherto,  it  has  generally  been  supposed 
that  electricity  acts  beneficially  by  a  direct  excitation  of  the  paralysed 
motor  nerves,  but  according  to  Benedikt*  this  is  not  so,  for  he  states 
that  its  effect  is  due  to  a  reflex  excitation  of  the  fifth.  He  found,  more- 
over, that  in  most  cases  a  curative  action  was  only  produced  when  the 
excitation  was  relatively  weak,  and  when  no  trace  of  miiscular  contrac- 
tion was  produced  by  the  electricity.  The  proper  measure  for  the 
strength  of  the  current  is  the  sensitiveness  of  the  fifth  pair.  If  the 
fifth  is  extremely  sensitive,  the  battery  may  have  to  be  reduced  to  four 
or  three  of  Daniell's  elements ;  if,  on  the  other  hand,  the  fifth  is  very 
insensible,  it  may  have  to  be  raised  to  12  or  15.  The  current  should 
be  sufficiently  intense  to  produce  a  slight  sensation  in  the  parts  excited, 
but  the  excitation  should  only  continue  for  about  half  a  minute  at  each 
sitting.  Experience  has  taught  Dr.  Benedikt  that  in  paralysis  of  the 
external  rectus  the  copper  pole  should  be  applied  to  the  forehead,  and 
the  zinc  pole  over  the  neighbourhood  of  the  cheek  bone.  In  mydriasis, 
the  latter  should  be  applied  to  the  same  place,  but  the  copper  pole  to 
the  closed  eyelid.  In  ptosis,  the  copper  pole  may  be  either  on  the  fore- 
head, or  may  be  applied  by  means  of  a  short  catheter-hke  reophore  to 
the  mucous  membrane  of  the  cheek,  while  the  zinc  pole  is  drawn  over 
the  lid.  For  all  the  other  branches  of  the  third  nerve,  the  copper 
pole  is  applied  as  above.  In  order  to  act  upon  the  internal  rectus  or 
inferior  oblique,  the  zinc  pole  should  be  drawn  over  the  skin  of  the  side 
of  the  nose,  near  the  inner  angle  of  the  eye,  and,  in  order  to  act  upon 
the  inferior  rectus,  over  the  lower  margin  of  the  orbit.  Benedikt  found 
that  in  the  greater  number  of  cases  the  improvement  takes  place  instan- 
taneously, as  shown  by  increased  mobility  of  the  eye,  and  a  diminution 
of  the  field  in  which  diplopia  arises ;  and  when  this  is  not  the  case,  a 
longer  continuance  and  increased  strength  of  the  excitation  is  not  indi- 

*  Vide  a  very  interesting  paper  by  Dr.  Moritz  Benedikt,  "  On  Electro-Thera- 
peutical and  Physiological  Researches  on  Paralysis  of  the  Ocular  Muscles."  "A.  f. 
O.,"  X,  1,  translated  in  "  Ophthalmic  Review,"  vol.  ii,  p.  143. 


SPASMODIC   AFFECTIONS   OF   THE   MUSCLES  OF   THE   EYE.      569 

cated.    "Wlien  tlie  paralysis  has  been  unaffected  by  14  days  of  treatment, 
he  has  not  seen  any  benefit  arise  from  its  longer  continuance. 

Pai'alytic  affections  of  the  muscles  of  the  eye  may  run  the  following 
different  courses  : — 1.  The  paralysis  may  be  completely  cured,  which  is 
most  likely  to  occur  when  the  affection  is  recent,  and  due  to  some  peri- 
pheral cause.  2.  The  cure  may  be  incomplete,  the  muscle  being  only 
partially  restored  to  its  former  power.  3.  The  paralysis  may  remain 
complete ;  but  this  condition  generally  soon  leads  to  the  next  (4)  state, 
viz.,  to  a  secondary  conti*action  of  the  opponent  muscle.  Thus  in  para- 
lysis of  the  left  external  rectus,  the  diplopia  may  extend  more  and  more 
into  the  right  half  of  the  visual  field,  and  a  decided  convergent  squint 
of  the  left  eye  be  apparent,  even  when  the  object  is  held  in  the  right 
half  of  the  field.  The  opponent  muscle  may  in  time  contract  so  much, 
as  to  drag  the  eye  almost  immoveably  to  its  own  side. 

When  all  other  remedies  have  failed  to  effect  a  cure,  it  may  be  neces- 
sary to  have  recourse  to  operative  interference,  and  the  nature  of  this 
will  depend  upon  the  degree  of  paralysis  which  remains  behind.  Thus, 
if  only  a  slight  degree  of  paralysis  of  the  external  rectus  remains,  so 
that  the  want  of  mobihty  outwards  amounts  to  about  1  or  1^  Kne,  divi- 
sion of  the  opponent  muscle  (internal  rectus)  will  be  indicated.  But 
when  the  immobility  exceeds  this  degree,  and  amounts  to  two  or  three 
lines,  this  operation  will  not  suffice,  and  we  must  combine  with  it  the 
operation  of  bringing  forward  the  insertion  of  the  paralysed  muscle 
(the  latter  operation  is  generally  termed  that  of  "re-adjustment"),  so  as 
to  increase  its  power  over  the  mobility  of  the  eyeball.  This  operation 
should  not  be  deferred  too  long,  for  after  a  time  the  paralysed  muscle 
may  undergo  fatty  degeneration,  which  renders  it  unfit  for  the  requisite 
degree  of  contraction,  even  if  its  innervation  were  completely,  or  in 
great  part,  restored ;  and  it  also  favours  secondary  contraction  of  the 
opponent.  The  method  of  performing  the  operation  of  re-adjustment 
will  be  considered  together  with  that  of  strabismus. 

9.— SPASMODIC  AFFECTIONS  OF   THE   MUSCLES  OF   THE 
EYE.     NYSTAGMUS,  ETC. 

The  symptoms  of  nystagmus  consist  in  a  peculiar,  restless  move- 
ment or  oscillation  of  the  eyeballs.  This  oscillation  is  generally  hori- 
zontal, but  occasionally  rotatory,  the  eyeballs  oscillating  round  the  axis 
of  the  oblique  muscles.  In  one  instance  I  have  seen  it  vertical,  in  an 
eye  affected  with  convergent  squint.  This  eye  made  a  constant,  vertical, 
upward  and  downward  movement,  which  was  not  arrested,  or  even 
improved,  by  the  tenotomy  of  the  internal  rectus.  This  is  the  only  case 
of  vertical  oscillation  with  which  I  have  ever  met.  The  oscillation 
may  be  periodical,  and  its  degree  is  often  very  variable  at  different  times, 


570       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

being  markedly  increased  by  any  nervons  excitement,  and  by  the  effort 
of  accommodation.  To  remedy  the  indistinctness  of  vision  produced 
by  tbe  unsteadiness  of  the  eyes,  the  patients  often  make  a  contrary 
movement  of  the  head ;  or  they  hold  the  print  in  a  slanting  or  vertical, 
instead  of  a  horizontal,  position,  so  that  the  lines  run  vertically  instead 
of  horizontally.  The  reason  of  this  is  easily  intelligible,  for  they  can 
then  see  the  individual  lines  chiefly  by  the  aid  of  the  superior  or  inferior 
recti,  and  the  circles  of  diffusion  caused  by  the  oscillation  of  the  eye  will 
then  extend  the  latter  vertically,  instead  of  horizontally;  the  length  of 
the  letters  will  consequently  be  considerably  more  increased  than  their 
breadth,  which  is  less  confusing  to  the  sight,  as  their  lateral  separation 
will  be  preserved.  Whereas,  when  they  are  extended  horizontally,  one 
letter  runs  into  the  other,  its  outhne  is  blurred  and  confused,  and  the 
power  of  distinction  much  impaired. 

Although  there  may  be  considerable  oscillation  of  the  eyeballs,  the 
movements  of  the  eyes  are  unaffected  and  perfect  in  all  directions,  and 
the  two  eyes  may  act  perfectly  together,  but  binocular  vision  is  often 
disturbed,  and  the  sight  of  the  two  eyes  frequently  very  different.  The 
oscillation  sometimes  diminishes  greatly,  or  is  even  arrested  when  the 
eyes  are  moved  very  far  outwards  or  inwards,  or  in  one  of  the  diagonal 
positions  downwards  (Bohm).* 

Nystagmus  generally  appears  in  early  infancy,  and  is  especially  met 
with  in  cases  in  which  a  considerable  degree  of  exertion  of  the  ocular 
muscles  is  required  for  distinct  vision ;  the  object  having,  perhaps,  to 
be  held  very  close  to  the  eye,  either  on  account  of  some  anomaly  of  the 
refraction,  or  some  opacity  in  the  refracting  media.  Thus  the  affection 
is  often  met  with  in  infants  together  with  opacities  of  the  cornea  or  of 
the  lens,  in  cases  of  strabismus,  in  albinos,  etc. 

The  disease  may  diminish,  or  even  disappear,  as  the  patient  grows 
older,  but  it  generally  remains  permanent,  varying,  perhaps,  somewhat 
with  the  state  of  health ;  any  debility  or  nervous  excitement  increasing 
its  intensity.  If  strabismus  co-exists,  this  should  be  cured  by  an 
operation,  and  in  some  cases  the  nystagmus  is  also  considerably 
diminished  by  the  tenotomy.  In  others  it  must,  however,  be  confessed, 
that  either  no  benefit,  or  only  a  very  tempoi-ary  one,  results,  flence  I 
do  not  consider  it  advisable  to  perform  tenotomy  of  any  of  the  ocular 
muscles  for  the  chance  of  curing  the  nystagmus,  except  there  is  also 
strabismus.  Any  anomaly  of  refraction  should  be  corrected  by  suitable 
lenses,  and  benefit  is  sometimes  experienced  from  the  use  of  blue  eye- 
protectors,  to  diminish  the  intensity  and  glare  of  the  light. 

Spasmodic  affections  of  the  ocular  muscles  are  extremely  rare. 
Clonic  spasms  are  sometimes  met  with  in  children  affected  with  chorea 
or  basilar  meningitis ;  also  in  cases  of  lead  poisoning,  and  in  some  of 
*  Bohm,  Der  Nystagmus. 


STRABISIMUS.  571 

the  affections  of  the  brain  and  spinal  cord.     Tonic  spasms  of  the  ocular 
muscles  are  occasionally  observed  in  epilepsy. 

Spasm  of  the  orbicularis  palpebrarum  is  described  in  the  article  upon 
the  diseases  of  the  eyelids. 

10.— STRABISMUS. 

We  have  now  to  turn  our  attention  to  the  consideration  of  the 
various  forms  of  squint  and  their  treatment.  The  surgeon  should 
thoroughly  master  the  theoretical  portion  of  this  subject  before  he 
attempts  to  operate  for  the  cure  of  this  affection ;  for  although  the 
operation  for  squint  is  not  per  se  a  difficult  one,  we  yet  meet  with 
many  cases  which  require  very  great  exactitude  and  nicety,  not  only  in 
the  preliminary  examination,  but  also  in  the  mode  of  operation.  Still 
more  difficult  and  intricate  are  those  cases,  in  which  we  operate  less  for 
the  cure  of  the  deformity,  which  is,  perhaps,  hardly  observable,  than 
for  the  purpose  of  freeing  the  patient  from  the  great  and  constant 
annoyance  of  the  diplopia.  These  demand  a  thorough  knowledge  of 
the  individual  actions  of  the  muscles  of  the  eyeball,  an  intimate 
acquaintance  with  the  various  forms  of  diplopia,  and  considerable 
manual  dexterity  in  the  performance  of  the  operation,  the  extent  and 
character  of  which  should  be  accurately  determined  upon  beforehand. 
These  cases,  indeed,  often  form  some  of  the  most  difficult  problems  in 
ophthalmic  surgery,  and  can  be  only  successfully  treated  by  those  who 
have  mastered  the  theory  of  this  and  kindred  subjects.  A  want  of  such 
knowledge  brought  the  operation  for  squint  into  almost  complete  dis- 
repute, and  we  are  chiefly  indebted  to  Von  Graefe  for  having  extricated 
it  from  the  obloquy  with  which  it  had,  not  undeservedly,  been  visited, 
and  for  having  rendered  it  one  of  the  most  successful  operations  in 
surgery.  He  has  achieved  this  success  not  so  much  by  improving  the 
mode  of  operation,  as  by  his  elaborate  researches  into  the  physiology 
and  symptomatology  of  the  various  forms  of  squint,  which  have  enabled 
him  to  lay  down  exact  data  for  their  successful  treatment. 

Symptomatically  we  mean  by  the  term  squint,  an  inability  to  bring 
both  visual  Hnes  to  bear  simultaneously  upon  one  point,  the  one  always 
deviating  in  a  certain  direction  from  the  object.  If  the  squinting  eye 
deviates  inwards,  it  is  called  convergent  squint,  if  outwards,  divergent 
squint ;  if  it  squints  upwards,  strabismus  sursumvergens,  if  downwards, 
strabismus  deorsumvergens. 

The  name  strabismus  was  formerly  indiscriminately  applied  to  all 
abnormal  deviations  of  the  visual  lines,  whatever  their  cause ;  whether 
they  were  due  to  paralysis  or  spasm  of  one  or  more  of  the  muscles  of 
the  eyeball,  or  whether  some  tumour,  etc.,  of  the  orbit  prevented  the 
free  movement  of  the  eye  in  certain  directions. 


572       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

We  now,  however,  limit  the  term  strabismus  (or  strabismus  con- 
com.itai]s  of  Von  Graefe,  a  name  we  shall  adopt)  to  that  group  of  cases 
which  presents  the  following  well-defined  and  constant  symptoms  : — 

1.  The  visual  hne  of  one  eye  being  fixed  upon  an  object,  that  of  the 
other  always  deviates  from  the  latter  at  a  certain  angle,  and  in  a  certain 
dii'ection.  In  convergent  squint  it  deviates  to  the  inner,  in  divergent 
squint  to  the  outer  side  of  the  object.  In  order  to  determine  which  is 
the  squinting  eye,  the  patient  should  be  directed  to  look  steadily  at  an 
object  (a  lighted  candle  or  our  uplifted  finger)  held  in  the  horizontal 
median  line,  at  the  distance  of  a  few  feet.  Then,  alternately  covering 
each  eye  vnth  our  hand,  we  note  whether  the  uncovered  eye  remains 
steadily  fixed  upon  the  object,  or  has  to  change  its  position  before  it 
can  bring  its  optic  axis  to  bear  upon  it.  In  the  former  case,  it  is  the 
one  generally  used  for  fixation,  in  the  latter,  it  deviates  from  the  object. 
We  may,  however,  fail  to  detect  the  deviation  in  this  manner,  if  it  is 
so  very  slight  as  to  be  almost  objectively  inappreciable,  in  which  case 
we  must  call  the  diplopia  to  our  aid,  as  it  enables  us  to  detect  the  most 
minute  deviations  of  the  optic  axes.  But  the  concomitant  squint  is 
generally  very  evident. 

If  we  cover  the  healthy  eye  with  our  hand,  the  other  will  move  in  a 
certain  direction  in  order  to  fix  the  object  (in  convergent  squint  it  will 
move  outwards,  in  divergent  inwards),  the  healthy,  covered  eye  raaking 
at  the  same  tirae  an  associated  movement  (which  has  been  designated 
the  secondary  deviation),  becoming  now,  in  fact,  the  squinting  eye. 

I  have  already  (p.  655)  explained  the  method  of  measuring  the 
linear  extent  of  the  deviation  with  Laurence's  strabismometer.  I  need 
only  add  that  the  degree  of  strabismus  should  be  tested  both  for  near 
and  distant  objects,  as  it  is  often  far  more  considerable  during  a  strong 
effort  of  accommodation,  as  in  reading  small  type,  than  when  the  eye 
is  looking  at  a  distant  object. 

We  sometimes  find  that  there  is  not  only  a  lateral  deviation,  but 
also  a  slight  difference  in  the  height  of  the  two  eyes.  It  is  important 
in  such  a  case,  to  determine  whether  (in  a  case  of  convergent  squint) 
this  is  due  to  the  upper  fibres  of  the  internal  rectus  being  more  contracted 
than  the  middle  or  lower  fibres,  or  whether  it  is  owing  to  the  superior 
rectus  being  also  affected,  for  upon  this  will  hinge  the  question  of 
operating  upon  more  than  one  muscle. 

The  associated  movement,  which  the  healthy  eye  makes  when  it  is 
covered  and  the  squinting  eye  fixes  the  object,  will  enable  us  to  deter- 
mine this,  for  if  the  internal  rectus  is  alone  at  fault,  the  associated 
movement  of  the  healthy  eye  will  be  only  lateral,  without  any  deviation 
in  height ;  whereas,  if  the  superior  rectus  is  also  implicated,  the  healthy 
eye  will  make  not  only  an  inward,  but  also  a  downward  movement, 
corresponding  to  the  outward  and  downward  movement  of  the  other 


STRABISMUS.  573 

eye.  In  the  former  case,  we  shall  almost  always  succeed  in  curing  the 
inward  and  slightly  upward  deviation  by  a  tenotomy  of  the  internal 
rectus  alone,  more  particularly  if  we  freely  divide  the  upper  portion  of 
the  tendon.  In  the  latter  case,  we  shall  have  not  only  to  operate  upon 
the  internal,  but  also  upon  the  superior  rectus. 

2.  The  primary  and  secondary  deviations  are  quite  equal  in  extent. 
The  meaning  of  these  terms  has  been  already  fully  explained  at  page 
554.  Let  us  suppose  that  the  left  eye  squints  inwards  to  the  extent 
of  two  lines.  Now,  if  the  right  is  covered,  the  left  will  have  to  move 
outwards  to  the  extent  of  two  lines  in  order  to  fix  the  object,  and  the 
covered  eye  will  make  at  the  same  time  an  associated  movement  in- 
wards of  two  lines,  this  secondary  deviation  being,  therefore,  exactly 
equal  to  the  primary. 

3.  The  extent  of  movement  of  the  two  eyes  is  quite  normal  and 
equal,  the  arc  of  mobility  being  exactly  of  the  same  extent  in  both 
eyes,  and  only  a  Httle  shifted  towards  the  side  of  the  shortened 
muscle.  Thus,  in  a  convergent  squint  it  is  shifted  slightly  inwards, 
but  what  is  gained  in  this  direction  is  lost  in  the  movement  outwards. 
This  increase  in  the  mobility  towards  the  side  of  the  shortened  muscle, 
is,  however,  very  slight  when  compared  with  the  degree  of  the  squint. 
On  account  of  this  complete  accompaniment  of  the  squinting  eye  in  all 
the  movements  of  the  healthy  one,  it  has  been  called  strabismus  con- 
comitans.  If  we  hold  an  object  in  the  horizontal  median  line,  and 
then  move  it  to  the  right  and  left,  the  optic  axis  of  the  squinting  eye 
will  exactly  accompany  that  of  the  healthy  eye  in  all  its  movements, 
deviating  from  it,  however,  always  at  the  same  angle,  except,  indeed,  at 
the  extreme  portions  of  the  field  of  vision. 

In  order  to  note  accurately,  and  to  keep  an  easy  and  diagrammatic 
record  of  the  extreme  lateral  movements  of  each  eye  inwards  and  out- 
wards, Mr.  Bowman  has  for  some  time  adopted  the  following  simple 
and  practical  method : — He  notes  the  extreme  range  inwards,  by  mark- 
ing the  position  of  the  pupil  on  extreme  inversion,  compared  with  that 
of  the  lower  punctum ;  and  the  extreme  range  outwards,  by  marking 
the  position  of  the  outer  edge  of  the  cornea,  on  extreme  eversion,  com- 
pared with  that  of  the  external  canthus. 

The  following  figui'es  illustrate  this  method,  the  patient  being  sup- 
posed to  face  the  observer : — 

Fig.  80  shows  i2,  the  right  outer  canthus,  and  L  the  left  outer 
canthus,  crossed  by  a  vertical  line  «,  or  &,  or  c,  which  indicates  by  its 
position  the  extent  to  which  the  outer  edge  of  the  cornea  approaches 
the  canthus,  or  even  goes  beyond  it,  on  extreme  eversion  of  the  eye.  And 
Fig.  81,  in  like  manner,  exhibits  for  B  the  right  eye,  and  for  L  the  left 
eye,  the  position  which  the  pupil,  0,  takes  with  regard  to  the  punctum, 
•  ,  when  the  eye  is  moved  inicards  to  the  extreme  degree.     It  may  fail 


574 


AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 


to  reach  it,  as  at  a  a,  or  be  over  it,  as  at  h  h,  or  pass  more  or  less  in- 
wards beyond  it,  as  at  c  c. 


< 


Fig.  80. 


<— c       ^-^  ^>^ 


c      b       a 


a       b       c  '  Tig.  81. 

E     000    S^i^   000    ^ 


In  taking  tbe  relation  of  the  pupil  to  the  punctnui  if  the  eye  is 
much  inverted,  the  observer  should,  as  it  were,  face  the  pupil  in  its 
inverted  position,  otherwise  the  interval  between  it  and  the  punctum  is 
not  so  correctly  estimated.  Or  the  parts  may  be  viewed  from  above, 
the  surgeon  raising  the  upper  lid,  and  standing  behind  the  patient,  who 
sits  on  a  chair.     But  a  little  practice  soon  renders  this  unnecessary. 

If  the  outer  edge  of  the  cornea,  in  extreme  eversion,  passes  under 
cover  of  the  canthus,  its  actual  position  can  be  readily  enough  marked 
by  noting  how  much  of  the  iris  is  covered  from  view. 

A  diagrammatic  record  should  be  kept  of  the  range  of  mobility,  in 
order  that  we  may  hereafter  be  able  to  estimate  the  efiect  of  the  opera- 
tion upon  the  lateral  movements  of  the  eye. 

The  accommodative  movements  of  the  eye  should  also  be  accurately 
tested,  for  they  are  extremely  important,  as  will  be  shown  hereafter, 
in  determining  the  mode  and  extent  of  the  operation.  On  bringing 
the  object  nearer  and  nearer  to  the  eyes,  the  optic  axis  of  the  healthy 
eye  will  remain  fixed  upon  it,  converging  the  more  the  nearer  the  object 
is  approximated :  the  position  of  the  squinting  eye  (convergent  stra- 
bismus) may,  at  the  same  time,  undergo  the  following  changes  : — 

1.  It  may  retain  its  original  position,  sustaining  only  a  few  oscil- 
lating, irregular,  lateral  movements. 

2.  It  may  remain  completely  stationary,  so  that  the  angle  of  squint- 
ing will  diminish  the  more,  the  nearer  the  object  is  brought,  until,  at  a 
certain  point  (if  the  squint  be  not  excessive),  its  optic  axis  will  also  be 
fixed  upon  the  object,  and  there  will  no  longer  be  any  squint.     If,  how- 


STRABISMUS.  575 

ever,  the  object  is  approximated  still  closer,  a  divergent  squint  will 
arise ;  for,  wliilst  the  healthy  eye  converges  still  more,  the  other  retains 
its  position,  and  now  deviates  (passively)  outwards. 

3.  It  retains  its  position  up  to  a  certain  point,  and  then,  as  the 
healthy  eye  moves  inwards  to  follow  the  object,  it  makes  an  associated 
movement  outwards. 

4.  It  deviates  suddenly  and  spasmodically  inwards,  when  the  object 
is  approximated  very  closely. 

Concomitant  squint  may  be  either  monolateral  or  alternating.  In 
the  former  case,  the  squint  is  always  confined  (when  both  eyes  are 
open)  to  one  and  the  same  eye.  Jf  the  healthy  eye  be  covered,  the 
other  will  move  in  order  to  fix  the  object,  but  directly  the  former  is 
again  uncovered,  it  will  at  once  resume  its  squinting  position.  In 
alternating  squint  it  is  different,  for  sometimes  the  one  eye  deviates, 
sometimes  the  other.  If  we,  in  this  case,  cover  the  healthy  eye,  the  other 
will  make  a  movement  in  order  to  adjust  its  optic  axis  upon  the  object, 
and  will  retain  its  position  when  we  uncover  the  sound  eye.  The  latter 
has  now,  in  fact,  become  the  squinting  one.  If  we,  then,  cover  the 
other,  the  squint  will  alternate  again.  It  appears  almost,  or  quite, 
immaterial  to  the  patient  which  eye  he  uses.  In  such  cases,  there  is 
generally  no  difference  in  the  sight  of  the  two  eyes ;  whereas,  in  mono- 
lateral  strabismus  the  vision  of  the  squinting  eye  is  almost  always 
affected,  on  account  of  the  suppression  of  the  double  image,  sometimes, 
indeed,  very  considerably. 

The  active  negation  of  the  double  image  by  the  brain,  soon  leads  to 
a  more  or  less  considerable  deterioration  in  the  sight  of  this  eye.  We 
occasionally  find,  however,  that  the  vision  of  the  squinting  eye  remains 
good,  although  the  strabismus  is  not  alternating.  Indeed,  I  have  seen 
cases  (exceptional  I  grant)  in  which  the  patients  could  read  the  very 
finest  print  with  it,  never  having,  as  far  as  they  could  remember, 
suffered  from  diplopia.  Here  binocular  vision  had  most  likely  never 
existed,  and  hence  the  absence  of  diplopia  and  the  call  for  the  sup- 
pression of  the  double  image. 

It  was  at  one  time  proposed  to  cure  squint  by  closing  the  healthy 
eye,  and  thus  necessitating  the  fixation  of  the  other  upon  the  object. 
The  error  of  such  treatment  is,  however,  self-evident,  as  the  squint  is 
merely  transferred  to  the  excluded  eye ;  for  just  the  same  thing  occurs, 
as  when  we  place  our  hand  over  the  healthy  eye,  in  order  to  estimate 
the  primary  and  secondary  deviation.  The  vision  of  the  squinting  eye 
is  exercised,  but  the  disease  remains  uncured.  But  this  proceedino- 
often  proves  very  valuable  in  practice,  for  by  it  we  may  render  a 
monolateral  squint  alternating,  and  preserve  the  sight  of  both  eyes. 
If,  for  instance,  a  child  squints  (seeing  perfectly  with  both  eyes),  and 
the  operation  has  to  be  postponed  for  some  reason,  we  may  preserve 


576       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

the  sight  of  the  squinting  eye  by  the  periodical  exclusion  of  the  other. 
In  this  way,  we  may  not  only  maintain  the  alternating  character  of  the 
strabismus,  and  the  sight  of  both  eyes,  but  we  may  even  change  a 
monolateral  into  an  alternating  squint. 

The  question  as  to  whether  binocular  vision  exists  or  not  in  a  case 
of  strabismus,  is  of  much  importance  in  the  prognosis.  For  if  it  does 
not  exist,  we  cannot  expect  a  perfect,  but  only  an  approximative,  cure, 
for  there  will  not  be  any  diplopia,  and  the  perfect  cure  of  squint 
depends  upon  the  fusion  of  the  double  images.  Hence,  the  presence  of 
binocular  vision  should  always  be  ascertained  before  the  prognosis  of  a 
strabismus  operation  is  made.  Its  presence  is  of  course  proved  at 
once  by  the  existence  of  binocular  diplopia.  The  sight  of  each  eye 
may  be  good,  and  there  may  be  no  deviation  of  the  optic  axes  when 
both  are  open,  and  yet  both  may  not  be  used  at  the  same  time.  The 
existence  of  binocular  vision  is  easily  proved  by  the  aid  of  prisms. 
Each  eye  should,  however,  be  first  examined  separately,  and  its  acuity 
of  vision,  range  of  accommodation,  and  state  of  refraction  be  accurately 
ascertained ;  notice  being  also  taken  as  to  whether  the  visual  line  is 
adjusted  upon  the  object,  or  whether  the  eye  "  fixes  "  the  latter  with 
an  eccentric  portion  of  the  retina,  and  not  with  the  yellow  spot. 
In  the  former  case  it  is  termed  "central,"  in  the  latter  "eccentric 
fixation."  The  patient  is  next  directed  to  look  with  both  eyes  at  a 
lighted  candle  situated  at  a  distance  of  4  or  6  feet,  and  a  prism,  with  its 
base  outwards,  is  then  placed  before  one  eye  (let  us  suppose  the  left). 
One  of  the  following  three  things  will  then  occur: — 1,  diplopia;  2, 
a  corrective  squint  if  the  prism  is  not  too  strong,  for  the  left  eye  will 
endeavour  to  overcome  the  annoyance  of  the  diplopia  by  squinting 
inwards,  and  thus  fusing  the  double  images ;  8,  the  prism  may  have  no 
effect,  producing  neither  diplopia,  nor  a  corrective  squint.  This  proves 
the  absence  of  binocular  vision,  and  that  the  prism  has  been  held  before 
the  eye  which  is  not  used.  For  if  we  place  it  (still  with  its  base  out- 
wards) before  the  other  eye,  this  will  move  inwards  in  order  to  bring 
the  deflected  rays  again  upon  the  yellow  spot,  this  being  accompanied 
by  an  associated  movement  outwards  of  the  eye  which  is  excluded  from 
binocular  vision. 

Binocular  vision  is  frequently  only  lost  in  certain  portions  of  the 
retina,  more  especially  in  those  which,  though  not  identical  with,  are 
constantly  excited  simultaneously  with  the  central  portion  of  the  retina 
of  the  other  eye. 

Thus  in  convergent  squint  we  find  that,  in  the  squinting  eye,  the 
portion  of  the  retina  which  lies  internal  to  the  yellow  spot  is  the  first 
to  suffer  a  loss  of  binocular  vision,  for  it  is  directed  towards  the  object, 
and  is  therefore  (though  not  identical  with  it)  constantly  excited 
simultaneously  with  the  central  portion  of  the  retina  of  the  other  eye. 


STRABISMUS.  577 

which  is  fixed  upon  the  object.  The  reverse  occurs  in  divergent  squint, 
for  there  the  external  portion  of  the  retina  is  the  first  to  fail.  At  first, 
this  loss  of  binocular  vision  only  extends  horizontally,  so  that  if  we  turn 
a  prism  with  its  base  upwards  or  downwards  (or  place  it  even  in  a 
diagonal  position),  we  at  once  produce  double  images,  which  show  not 
only  a  difference  in  height,  but  also,  if  there  is  any  squint,  a  lateral 
difference.  We  may  thus  determine  Avith  the  greatest  nicety,  which 
part  of  the  retina  has  lost  the  power  of  binocular  vision.  Sometimes 
it  extends  over  the  whole  retina,  so  that  we  fail  to  produce  diplopia 
even  with  the  strongest  prisms  turned  in  any  direction ;  in  other  cases, 
this  loss  of  binocular  vision  is  tolerably  circumscribed,  being  confined 
to  a  veiy  small  portion  of  the  retina.  In  convergent  strabismus,  for 
instance,  only  a  small  portion  of  the  retina  internal  to  the  yellow  spot 
may  have  suffered ;  so  that  on  placing  a  prism,  with  its  base  towards 
the  nose,  before  this  eye,  and  deflecting  the  rays  still  more  inwards, 
double  images  are  at  once  produced,  although  the  deflected  rays  now 
impinge  upon  a  more  eccentric,  and  naturally  less  sensitive  por- 
tion of  the  retina.  Occasionally,  we  may  in  such  a  case  also  produce 
diplopia,  if  we,  by  means  of  a  prism,  bring  the  rays  ne^irer  to  the 
macula  lutea.  Thus,  a  sudden  alteration  of  the  position  of  the  optic 
axis  of  the  afiected  eye,  may  at  once  give  rise  to  diplopia ;  as,  for 
instance,  alter  the  operation  for  squint,  or  in  cases  of  paralysis  or  spasm 
of  the  other  muscles  of  the  eyeball. 

Von  Graefe  has  found  that  binocular  vision  is  absent  in  about 
90  per  cent,  of  cases  of  concomitant  squint ;  that  we  can  produce 
diplopia  by  prisms  in  about  25  per  cent. ;  and  that  after  the  operation, 
binocular  vision  is  found  to  exist  in  about  50  per  cent.  The  reason 
why  binocular  vision  is  so  frequently  absent  in  concomitant  squint  is, 
that  on  account  of  the  annoyance  and  confusion  produced  by  the 
diplopia,  the  patient  soon  acquires  the  habit  of  mentally  suppressing 
the  retinal  image  of  the  squinting  eye.  This  active  suppression  of  the 
pseudo-image  is  mostly  accompanied  by  considerable  amblyopia,  and 
the  latter  is  especially  apt  to  increase  very  rapidly  in  children,  so  that, 
perhaps,  within  a  few  months  after  the  first  appearance  of  the  squint, 
the  child  may  hardly  be  able  to  decipher  large  letters  (No.  16  or  20 
of  Jjiger)  with  the  squinting  eye.  This  being  so,  the  operation  should 
never  be  unnecessarily  deferred.  The  question  is  often  debated,  as  to 
whether  a  child  of  two  or  three  years  of  age  should  be  operated  upon 
for  squint,  or  whether  it  is  not  better  to  postpone  the  operation  until 
it  is  much  older.  My  opinion  is  very  strongly  opposed  to  the  latter 
practice,  and  is  urgently  in  favour  of  the  operation  being  performed  as 
soon  as  possible,  whilst  binocular  vision  still  exists,  and  the  sight 
of  the  squinting  eye  is  good.  If  it  is,  however,  absolutely  necessary  to 
postpone  the   operation,   the    vision    of  the    squinting  eye  should  be 

2  p 


57b  AFFECTIONS   OF   THE   MUSCLES   OF   THE   EYE. 

very  frequently   practised,   and   eacli  eye   alternately    used  for    read- 
ing, etc. 

The  amblyopia  due  to  tlie  suppression  of  the  retinal  image  is  often 
greatly  improved  by  the  operation,  and  especially  by  practising  the 
sight  afterwards  with  a  strong  convex  lens,  or  by  Von  Graefe's  arrange- 
ment of  two  lenses  placed  in  a  short  tube  (p.  408).  The  improve- 
ment produced  by  the  operation  varies  with  the  degree  of  amblyopia, 
and  is  greatest  when  the  patient  can  still  read  moderate  sized  print 
(fromKo.  4  to  14  Jiiger),  when  the  sight  is  improved  by  convex  glasses, 
and  when  the  fixation  is  central  and  the  visual  field  good. 

The  sudden  and  very  marked  improvement  of  sight  which  occa- 
sionally takes  place  directly  after  the  division  of  the  tendon,  is  probably 
due  to  the  relief  of  the  compression  exercised  by  the  contracted  muscle 
upon  the  sclerotic,  and  through  it  upon  the  i-etina.  It  is  ditficult  other- 
mse  to  explain  this  very  sudden  and  striking  improvement  of  vision. 

We  must  now  briefly  consider  the  different  forms  of  strabismus,  and 
the  various  causes  that  may  give  rise  to  them.  Before  doing  so,  I  must, 
however,  again  call  attention  to  the  fact  that  we  occasionally  meet  with 
cases  of  apparent  strabismus.  In  such  there  is  an  undoubted  and  well 
marked  deviation  (either  convergent  or  divergent)  of  the  optic  axes, 
and  yet  both  eyes  are  steadily  fixed  upon  the  object,  and  neither  moves 
in  the  slightest  degree  when  the  other  is  closed.  Hence  the  squint  is 
not  real,  but  only  apparent.  Donders  has  called  particular  attention 
to  this  fact,  and  has  furnished  us  with  the  explanation. 

I  have  already  mentioned  (p.  494)  that  according  to  Helmholtz, 
the  optic  axis  and  the  visual  line  (an  imaginary  line  drawn  from  the 
yellow  spot  to  the  object-point)  do  not  correspond,  but  that  the  latter 
impinges  upon  the  cornea  slightly  to  the  inner  side  of  the  optic  axis, 
forming  with  it  an  angle  of  about  5°.  It  will,  therefore,  be  at  once 
apparent,  that  if  the  visual  lines  are  parallel,  the  optic  axes  must  neces- 
sarily be  slightly  divergent,  and  such  is,  indeed,  the  case  in  the  normal 
eye,  but  this  divergence  is  so  very  slight,  and  we  are  so  accustomed  to 
it,  that  it  escapes  our  observation.  In  some  cases,  the  visual  line  may 
change  its  position  with  respect  to  the  optic  axis,  and  if  this  deviation 
be  at  all  considerable,  an  apparent  squint  will  arise  In  myopia,  for 
instance,  the  visual  line,  instead  of  lying  to  the  inner  side  of  the  optic 
axis,  may  correspond  to  the  latter,  or  even  lie  to  the  outer  side  of  it ; 
and,  in  the  latter  case,  there  will,  consequently,  be  an  apparent  con- 
vergent squint ;  for  whilst  the  visual  lines  meet  in  the  object-point,  the 
optic  axes  must  necessarily  cross  on  this  side  of  it.  In  hypermetropic 
eyes  the  reverse  may  obtain  ;  the  visual  line  may  lie  more  than  normally 
to  the  inner  side  of  the  optic  axis,  forming  with  it,  perhaps,  if  the 
hypermetropia  be  excessive,  an  angle  of  8°  or  even  9°,  instead  of  one 
of  5°.     If  such  eyes  look  at  a  distant  object,  they  will  appear  to  be 


CONVERGENT    STRABISMUS.  579 

affected  with  a  divergent  squint,  for  whilst  the  visual  lines  are  fixed 
upon  the  object,  the  optic  axes  will  diverge  from  it.  This  explanation 
of  Donders'  is  not  only  exceedingly  interesting,  but  is  also  of  much  use 
to  us  in  practice,  for  it  will  guard  us  against  an  erroneous  diagnosis  and 
treatment  of  such  cases*.  Some  of  the  cases  of  so  called  incongruence 
of  the  retince  were  probably  really  cases  of  apparent  strabismus. 


(1.)   CONVERGENT  STRABISMUS. 

Convergent  squint  is  in  the  vast  majority  of  cases  duo  to  hyperme- 
tropia.  According  to  Donders,t  the  latter  is  present  in  about  75  per 
cent,  of  the  cases  of  convergent  strabismus.  Weckcr  places  it  even  at 
a  higher  figure  (85  per  cent.).  The  presence  of  hypermetropia  is  often 
overlooked,  because  it  is  either  latent,  or  because  the  patients  are  very 
young  and  do  not  know  how  to  read.  The  ophthalmoscope  would, 
however,  in  such  cases,  at  once  enable  us  to  detect  the  true  state  of 
refraction. 

It  Avill  be  remembered  that  we  understand  by  the  term  "hy[3erme- 
tropia,"  that  condition  of  the  eye  in  which  its  refracting  power  is  too 
low,  or  the  optic  axis  (antero-posterior  axis)  too  short,  so  that  rays 
which  impinge  parallel  upon  the  eye  (emanating  from  distant  objects) 
are  not  brought  to  a  focus  upon  the  retina,  when,  the  eye  is  in  a  state 
of  rest,  as  occurs  in  the  normal  eye,  but  more  or  less  behind  it,  accord- 
ing to  the  amount  of  hypermetropia  present.  The  effect  of  this  low 
refractive  condition  is,  that,  whilst  the  normal  eye  unites  rays  from 
distant  objects  upon  the  retina  without  any  accommodative  effort,  the 
hypermetropic  eye  has  already,  in  order  so  to  do,  to  exert  its  power  of 
accommodation  more  or  less  considerably.  This  exertion  must  increase, 
of  course,  in  direct  ratio  with  the  approximation  of  the  object  to  the 
eye ;  for  if  the  accommodation  has  already  to  be  brought  into  play  to 
unite  parallel  rays  upon  the  retina,  how  much  more  must  this  be  the  case 
when  the  object  is  closely  approximated,  and  the  rays  from  it  impinge  in 
a  very  divergent  direction  upon  the  eye.  Now,  in  order  to  increase  the 
power  of  accommodation,  one  eye  often  squints  inwards,  for  the  following 
reason  : — Because  together  with  the  increase  in  the  convergence  of 
the  optic  axes,  there  is  also  an  increase  in  the  power  of  accommodation. 
We  can  easily  prove  the  truth  of  this  statement,  by  placing  a  prism 
(with  its  base  outwards)  before  a  hypermetropic  eye  ;  for  the  latter,  in 

*  Although  the  visual  line  and  the  optic  axis  do  not  eoiTespond,  I  shall  yet 
generally  use  the  term  "  optic  axis  "  in  speaking  of  the  deviation  of  the  eyes  in  squint, 
60  as  to  prevent  the  confusion  which  woidd  arise  if  different  terms  were  emijloyed. 

+  Vide  Donders'  article  on  "The  Pathogeny  of  Squint,"  "A.  f.  O.,"  ix,  1,  1)9; 
also  an  able  translation  of  this  by  Dr.  Wright,  of  Dublin. 

2   P  2 


5«0       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

looking  at  distant  objects,  will  then  squint  inwards,  in  ordei'  to  avoid 
diplopia,  and  this  convergence  of  the  optic  axes  will  now  enable  it  to 
unite  parallel  rays  (from  distant  objects)  upon  the  retina,  whereas, 
when  its  optic  axes  were  parallel,  it  could  only  unite  convergent  rays. 
Again,  on  placing  a  concave  lens  before  a  normal  eye,  we  change  it 
into  a  hypermetropic  one,  for  parallel  rays  are  now  united  behind  the 
retina,  and  it  will  require  either  a  convex  glass  or  an  effort  of  the 
accommodation,  to  bring  these  rays  once  more  to  a  focus  on  the  retina. 
If  this  concave  glass  be  but  weak,  an  increased  effort  of  the  accom- 
modation will  neutralize  its  effect,  and  overcome  this  artificial  hyper- 
metropia.  If,  however,  the  concave  lens  be  too  strong  for  this,  the  eye 
often  overcomes  its  effect  by  squinting  inwards,  and  thus  increasing  its 
power  of  accommodation.  This  shows,  therefore,  apart  from  other 
consequences,  the  danger  of  giving  a  short-sighted  person  too  strong  a 
glass,  for  we  may  thus  induce  a  convergent  squint.  Now,  the  same 
thing  often  occurs  in  hypermetropia, — the  one  eye  squinting  inwards  in 
order  to  increase  the  power  of  accommodation.  At  first,  this  squint  is 
but  periodic,  appearing  only  when  the  patient  is  intently  regarding 
some  object.  As  soon  as  he  looks  at  any  object,  near  or  distant,  the 
one  eye  moves  inwards.  Frequently,  however,  the  squint  only  occurs 
when  he  is  looking  at  near  objects,  as  in  reading,  writing,  etc.  This 
squint  has,  therefore,  been  termed  periodic  squint ;  and  hypermetropia 
is  by  far  the  most  frequent  cause  of  it.  It  is  even  surprising  that 
squint  is  not  more  common  amongst  the  hypermetropic.  This  form  of 
periodic  strabismus  is  often  met  with  in  young  children,  frequently 
showing  itself  first  about  the  fourth  or  fifth  year,  when  they  are  learning 
to  spell,  etc.  In  such  cases,  we  may  fail  (on  only  cursorily  glancing 
at  the  eyes)  to  detect  the  slightest  squint ;  if  we,  however,  direct  the 
patient  to  look  fixedly  at  something — as  in  reading,  etc. — one  eye 
directly  squints  inwards,  this  deviation,  however,  disappearing  again  as 
soon  as  the  object  is  removed.  Sometimes  this  periodic  squint  shows 
itself  whenever  the  person  is  looking  intently  at  any  object,  be  it  near 
or  distant ;  in  other  cases,  however,  it  only  occurs  when  the  eyes 
are  looking  at  near  objects,  the  squint  disappearing  as  soon  as  they 
regard  distant  objects.  The  squint  may,  also,  be  frequently  corrected 
by  placing  suitable  convex  glasses  before  the  eyes,  so  as  to  neutralize  the 
hypermetropia.  If  the  latter  is  not  neutralized  by  the  constant  use  of 
convex  lenses,  the  squint  will  generally  soon  become  permanent, 
acquiring  then  all  the  symptoms  of  concomitant  squint.  As  hyperme- 
tropia is  often  hereditary,  and  frequently  exists  in  several  members  of 
the  same  family,  and  as  it  also  often  causes  strabismus,  the  popular 
idea  that  a  squint  may  be  produced  by  imitation,  has  gained  con- 
siderable credence,  even  in  the  Profession.  I  have  often  had  occasion 
to  examine  such  cases  of  squint  occurring  in  different  members  of  the 


CONVERGENT   STRABISMUS.  581 

same  family,  and  have  almost  invariably  found  that  both  patients,  the 
supposed  imitator  and  the  imitated,  have  been  hypermetropic  ;  a  com- 
mon cause  had  produced  the  same  affection. 

The  reason  why  the  majority  of  hypermetropic  persons  do  not 
squint,  is  evidently  due  to  the  fact,  as  pointed  out  by  Bonders,  that 
they  prefer  to  sacrifice  a  certain  degree  of  distinctness  and  sharpness 
of  vision  in  order  to  avoid  diplopia.  This  is  often  proved  by  the 
fact,  that  if  Ave  cover  the  one  eye  of  a  hy]Dermetropic  patient  with 
our  hand,  it  will  soon  deviate  inwards  when  the  other  is  used  for 
reading,  etc.  But  it  is  otherwise  when  the  images  of  the  two  eyes  are 
very  different  as  regards  distinctness,  as  for  instance,  if  the  degree  of 
hypermetropia  is  much  greater  in  the  one  eye  than  in  the  other,  or  if 
there  is  some  opacity  in  the  refracting  media  of  the  one  eye.  In  such 
cases,  a  convergent  squint  easily  becomes  developed.  The  same  occurs 
if  the  internal  recti  muscles  are  very  strong.  A  great  difference 
))etween  the  position  of  the  visual  line  and  the  optic  axis  (the  two 
forming  a  considerable  angle)  seems  also  in  hypermetropic  eyes,  to  pre- 
dispose to  strabismus  (Bonders). 

Convergent  squint  is  most  frequently  met  with  in  the  moderate 
degrees  of  hypermetropia  (from  -^  to  y'^  ),  being  generally  absent  in  the 
high  degrees.  This  is  evidently  due  to  the  fact,  that  when  the  hyperme- 
tropia is  very  considerable  in  degree,  the  accommodation  is  insufficient 
(even  when  the  visual  lines  are  abnormally  converged)  to  produce  a  per- 
fect retinal  image,  and  the  patient  therefore  accustoms  himself  to  gain 
correct  ideas  from  imperfect  representation,  rather  than  improve  these 
by  a  maximum  of  effort  (Bonders). 

Impaired  vision  of  the  one  eye  is  a  frequent  cause  of  strabismus,  as 
we  can  often  notice  in  cases  of  opacity  of  the  cornea  or  of  the  lens,  or 
of  some  affection  of  the  deeper  structures  of  the  eye ;  the  distinctness 
of  the  retinal  image  of  the  affected  eye  being  consequently  impaired. 
This  difference  in  the  clearness  and  intensity  of  the  retinal  images  of 
the  two  eyes  is  often  very  confusing  and  annoying  to  the  patient,  and, 
in  order  to  escape  from  this  annoyance,  he  involuntarily  squints  with 
the  affected  eye,  so  that  the  rays  from  the  object  may  impinge  upon  a 
more  peripheral  (and,  therefore,  less  sensitive)  portion  of  the  retina ; 
and  the  image  of  this  eye  be  consequently  so  much  weakened  in  in- 
tensity as  not  to  prove  any  longer  of  annoyance.  The  direction  in 
which  this  deviation  may  take  place,  is  generally  determined  by  the 
relative  strength  of  the  different  muscles.  If  one  proves  pre-eminently 
strong,  the  eye  will  squint  in  the  direction  of  this  muscle.  The  latter 
will  contract  more  and  more,  and  the  squint  will  soon  assume  all  the 
characters  of  concomitant  strabismus.  The  image  of  the  squinting 
eye  will  be  gradually  suppressed,  and  then  amblyopia  from  non-use  of 
the  eye  wiU  be  superadded  to  the  weakness  of  sight  caused  by  the 


582       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

original  affection  (opacities  in  the  refracting  media,  etc.).  It  must, 
however,  be  admitted,  as  has  been  pointed  out  by  Pagenstecher,  that  in 
very  many  of  these  cases  of  impaired  vision  hypermetropia  co-exists,  and 
must,  therefore,  be  regarded  as  the  true  cause  of  the  squint.  Bonders 
thinks  that  the  inflammation  which  causes  the  corneal  opacity,  may 
extend  to  some  of  the  muscles,  and  at  first  bring  on  a  spasmodic  and 
then  an  organic  contraction  of  the  muscular  tissues.  Convergent  squint 
may  also  arise  as  a  secondary  affection,  after  paralysis,  or  wounds  and 
injuries  of  the  opponent  muscle.  Marked  instances  of  this  secondary 
form  of  squint  are  but  too  often  furnished  by  excessive  operations  for 
strabismus ;  the  extent  of  the  opei'ation  having  either  been  too  great 
for  the  requirements  of  the  case,  or  the  muscle  having  been  divided 
instead  of  the  tendon.  Spasmodic  contraction  of  the  internal  rectus 
may  also  produce  convergent  squint,  but  this  does  not,  strictly  speaking, 
belong  to  our  present  subject. 

Von  Graefe*  has  pointed  out,  that  in  rare  instances  myopia  may  be 
the  cause  of  convergent  squint.  This  occurs  only  in  cases  in  which 
the  myopia  is  moderate  in  extent,  and  in  which  the  eyes  are  much  used 
for  very  near  work.  After  a  time,  the  internal  recti  become  contracted 
from  this  constant  and  excessive  use,  and  cannot  be  relaxed  when  the 
patient  looks  at  a  distant  object,  the  external  recti  being  too  weak  to 
overcome  the  action  of  the  internal  recti.  Consequently,  a  convergent 
squint  arises,  which  is  at  first  periodic,  but  may  in  time  become  per- 
manent, and  appear  as  soon  as  the  patient  looks  at  any  object  which  is 
not  very  close  to  him. 

This  squint  is  not  met  with  in  cases  of  very  considerable  myopia, 
because  in  these  the  necessary  convergence  of  the  optic  axes  can  gene- 
rally not  be  maintained  on  account  of  the  close  proximity  of  the  object, 
and  therefore  the  patient  only  uses  one  eye.  This  form  of  strabismus 
mostly  becomes  developed  in  early  manhood,  more  especially  amongst 
students  or  literary  men  who  are  not  in  the  habit  of  wearing  glasses. 


(2.)   DIVERGENT   STRABISMUS,  ETC. 

Just  as  hypermetropia  is  by  for  the  most  frequent  cause  of  con- 
vergent squint,  myopia  is  the  most  frequent  cause  of  divergent 
strabismus.  The  latter  may  be  constant  or  absolute,  the  one 
visual  line  always  diverging  from  the  object,  and  this  divergence 
existing  for  all  distances,  so  that  both  eyes  cannot  be  brought  to  con- 
verge upon  the  object  at  any  distance.  The  divergence,  however, 
sometimes  diminishes  somewhat  when  near  objects  are  regarded. 
This  absolute  divergence  is  especially  met  with  in  cases  in  which  the 

*  "A.  f.  0.,"x,  1,  156. 


DIVERGENT   STRABISMUS.  583 

sight  of  one  eye  is  greatly  impaired  (amaurosis,  mature  cataract,  etc.), 
in  paralysis  of  the  internal  rectus  muscle,  or  in  cases  in  which  the 
latter  has  been  too  freely  divided  in  an  operation  for  convergent 
squint. 

The  principal  cause  why  myopic  ej^es  are  so  subject  to  divergent 
strabismus,  is  to  be  sought  in  the  elongation  of  the  antero-posterior 
axis  of  the  eyeball  in  myopia.  On  account  of  the  ellipsoidal  shape  of 
the  globe,  its  range  of  mobility  is  diminished,  and  it  cannot  be  moved 
so  freely  inwards  or  outwards.  The  outward  limitation  of  mobility 
does  not  matter  much,  as  it  only  comes  into  account  in  the  extreme 
lateral  movements  of  the  eye,  and  the  inconvenience  arising  from  it 
can  easily  be  remedied  by  a  turn  of  the  head. 

We  find,  however,  that  it  is  very  different  if  there  is  a  considerable 
curtailment  of  the  inward  movement,  as  the  necessary  degree  of  con- 
vergence for  a  very  near  point  can  then  only  be  maintained  with  great 
difficulty  and  exertion.  The  internal  recti  muscles  are  much  strained 
and  fatigued,  symptoms  of  asthenopia  appear,  and  then,  to  relieve  these 
and  the  strong  muscular  effort,  one  eye  is  allowed  to  deviate  outwards  ; 
when  the  work  can  be  continued  without  difficulty.  This  is  one 
form  of  periodic  or  relative  divergent  strabismus,  and  the  same  thing 
occurs,  as  Donders  has  pointed  out,  whenever  the  degree  of  myopia  is 
so  extreme,  that  the  object  has  to  be  approximated  so  closely  to  the 
eye,  that  the  visual  lines  cannot  possibly  be  brought  to  converge  upon 
it.  Relative  divergence  may  be  due  simply  to  the  elongation  of  the 
eyeball,  together  with  great  myopia,  the  internal  recti  being  healthy ; 
or  to  weakness  of  the  internal  recti,  without  the  presence  of  myopia ; 
but  in  most  instances  these  two  causes  co-exist.  The  tendency  to 
divergent  squint  is  also  increased,  by  the  small  angle  which  the  visual 
line  forms  with  the  optic  axis  in  cases  of  myopia.  We  also  find  that 
divergent  squint  may  only  appear  when  the  myopic  patient  is  looking 
at  any  object  beyond  his  far  point,  and  which  he  does  not  see  distinctly  ; 
or  that  it  occurs  when  he  is  looking  vacantly  before  him  withovit  fixedly 
regarding  any  object.  On  account  of  the  indistinctness  of  the  object, 
there  is  no  effort  at  binocular  vision,  and  the  one  eye  will  follow  its 
natui'al  muscular  impulse,  and  deviate  outwards,  if  the  external  rectus 
is  relatively  stronger  than  the  internal.  But  if  the  patient  is  fur- 
nished with  suitable  concave  glasses  for  distance,  so  that  he  can 
see  the  objects  clearly  and  distinctly,  the  desire  to  maintain  binocular 
vision  will  overcome  the  divergence  ;  the  same  occurring  if  he  is  lookino- 
at  any  object  within  his  range  of  accommodation.  When  one  eye  is 
blind,  or  there  is  a  great  difference  in  the  refraction  of  the  two  eyes, 
divergent  strabismus  frequently  occurs.  For  as  there  is  no  impulse  to 
maintain  binocular  vision,  the  internal  rectus  gradually  diminishes  in 
strength,  and  the  external  rectus  perhaps  undergoes  secondary  con- 


584  AFFECTIONS   OF   THE   MUSCLES   OF   THE  EYE. 

traction.  The  relative  form  of  divergent  squint  dependent  upon 
insufficiency  of  the  internal  recti,  is  a  subject  of  such  great  import- 
ance, and  one  which  demands  such  careful  and  special  examination 
and  treatment,  that  I  shall  treat  of  it  separately,  under  the  name  of 
"  muscular  asthenopia." 


We  must  now  pass  on  to  the  treatment  of  strabismus.  The  nature 
of  concomitant  squint  is  totally  different  from  that  of  the  paralytic.  In 
the  latter,  the  innervation  of  one  or  more  of  the  muscles  of  the  eye- 
ball is  impaired ;  whereas,  concomitant  squint  is  due  to  a  change — 
an  increased  degree  of  tension — in  the  muscle  in  the  direction  of  which 
the  squmt  occurs.  But  its  innervation  is  normal,  as  is  at  once  proved 
by  the  perfect  mobility  of  the  eyeball  in  this  direction,  and  by  the  fact, 
that  the  secondary  deviation  exactly  equals  the  primary,  and  does  not 
exceed  it,  as  in  cases  of  paralysis.  Practically,  we  may  regard  the 
affected  muscle  as  shortened.  We  often  meet  with  mixed  forms  of 
squint,  for  paralytic  and  spasmodic  affections  of  the  muscles  of  the  eye 
may  give  rise  to  concomitant  squint,  leaving  behind  them  but  very 
slight  traces  of  the  original  affection.  But  just  as  paralysis  may  be 
the  cause  of  concomitant  squint,  so  may  the  latter,  if  it  be  excessive  in 
degree  and  of  long  standing,  produce  changes  in  the  opponent  muscle. 
Let  us,  for  instance,  suppose  that  there  is  an  excessive  convergent 
squint  of  the  one  eye :  if  the  latter  is  not  frequently  exercised,  and 
made  to  fix  its  optic  axis  upon  the  object  either  by  an  artificial  or 
natural  alternation,  the  non-use  of  the  external  rectus  will  gradually 
induce  atrophy  of  this  muscle.  The  internal  rectus  will  at  the  same 
time  become  somewhat  hypertrophied,  and  the  mobility  of  the  eye  out- 
wards will  be  considerably  curtailed.  These  changes  in  the  structure 
of  the  muscles  are  best  prevented  by  the  frequent,  separate  exercising 
of  the  squinting  eye. 

In  slight  cases  of  strabismus,  it  niay  be  advantageous  to  exer- 
cise the  weaker  muscle  by  frequent  and  systematic  "  orthopsedic " 
exercises  ;  so  that  it  may  be  gradually  strengthened,  and  enabled  to 
overcome  the  excessive  action  of  its  opponent  in  the  direction  in  which 
the  eye  is  deviated.  Such  exercises  are,  however,  only  indicated  when 
the  squinting  eye  possesses  a  fair  degree  of  sight;  when  binocular 
vision  exists ;  and  when  there  is  intolerance  of  diplopia,  so  that  when 
the  double  images  are  brought  sufficiently  close  together,  they  are 
fused  into  one  by  a  voluntary  muscular  effort.  These  exercises  may 
be  performed  by  the  aid  of  prisms,  the  double  images  being  approxi- 
mated so  closely  to  each  other,  that  they  can  be  readily  united.  As 
the  strength  of  the  muscle  increases,  that  of  the  prism  must  be  dimi- 
nished,  for  thus   the  distance  between  the  images  will  be  increased, 


TREATMENT    OF    STRABISMUS.  585 

and  tlie  muscle  more  exerted.  Javal*  has  introduced  a  very  ingenious 
stereoscopic  arrangement  for  these  orthopaedic  exercises.  The  latter 
consist  in  the  fusion  of  two  large  dots  (one  in  each  half  of  the  stereo- 
scope), and  subsequently  of  letters  and  words,  gradually  diminishing 
in  size.  But  both  the  prismatic  and  stereoscopic  exercises  demand 
very  great  patience  and  exactitude,  and  hence  most  patients  infinitely 
prefer  the  more  speedy  cure  by  operation.  But  these  exercises  often 
prove  very  useful  in  perfecting  the  results  of  an  operation.  The  sight 
of  the  squinting  eye  should  also  be  often  practised  by  itself. 

Absolute  concomitant  squint  can  be  cured  only  by  an  operation. 

The  object  of  the  operation  is  to  weaken  the  muscle  in  whose  direc- 
tion the  squint  occurs,  so  that  its  influence  upon  the  movements  and 
position  of  the  eyeball  may  be  diminished.  This  is  effected  by  care- 
fully dividing  the  tendon  as  closely  as  possible  to  its  insertion ;  the 
muscle  will  then  recede  slightly,  and  acquire  a  new  insertion  some- 
what fui'ther  back.  This  recession  is,  however,  accompanied  by  a 
certain  diminution  of  power,  for  the  further  back  the  insertion  lies,  the 
less  power  can  the  muscle  exercise  upon  the  movements  of  the  eyeball. 
As  we  wish  to  weaken  the  muscle,  but  at  the  same  time  to  preserve  as 
much  of  the  lateral  mobility  as  possible,  we  must  carefully  regulate  and 
adapt  the  amount  and  nature  of  the  operation  to  the  requirements  of 
each  individual  case,  and  we  shall  see,  hereafter,  how  its  effect  may 
always  be  estimated  to  a  nicety.  The  success  depends  less  upon  manual 
dexterity,  than  upon  a  thorough  knowledge  of  the  theoretical  part  of 
the  subject. 

After  the  tenotomy  and  retrocession  of  the  muscle,  the  eyeball  will 
incline  passively  to  the  side  of  the  opponent  to  about  the  same  extent 
as  the  muscle  receded  on  the  sclerotic.  The  diminution  in  the  lateral 
mobility  towards  the  side  of  the  operated  muscle,  will,  however,  exceed 
the  extent  of  this  retrocession.  If,  for  instance,  the  muscle  has  i-eceded 
two  lines,  the  loss  of  mobility  will  be  from  two  to  three  lines,  and  this 
would  impair  the  results  of  the  operation  considerably  (particularly 
with  regard  to  the  accommodative  movements)  if  it  was  not  for  the 
fact,  that  the  mobility  of  the  squinting  eye  is  pathologically  increased 
towards  the  side  of  the  shortened  muscle.  Hence,  the  mobility  will  be 
in  reality  but  slightly  diminished  by  the  operation,  or  it  may  even 
remain  equal  to  that  of  the  other  eye. 

The  question,  whether  one  or  both  eyes  are  to  be  operated  upon, 
does  not  hinge  upon  the  fact  whether  both  eyes  squint  or  not,  but 
depends  solely  upon  the  extent  of  the  strabismus.  It  is  quite  erroneous 
to  confine  the  operation  to  one  eye,  merely  because  the  squint  is  mono- 
lateral,  and  to  perform  the  double  operation  only  in  cases  of  alternating 
strabismus. 

*  "  Annales  d'Oculistique,"  1863,  p.  76  ;  also  1867,  p.  5. 


586       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

If  the  squint  measures  from  2  to  2^'"  we  may  generally  correct  it 
by  a  single  operation ;  by  incising  the  subconjunctival  tissue  somewhat 
freely,  and,  by  using  a  larger  hook,  we  may  even  obtain  an  effect  of 
2^  or  3'".  This  is  particularly  the  case  in  children.  If  the  deviation 
exceeds  2^  or  3'"  we  must  always  divide  the  operation  between  the  two 
eyes. 

Let  us  suppose,  for  instance,  that  a  patient  is  affected  with  a  con- 
vergent squint  of  the  right  eye  of  about  4^'".  To  correct  this  by  one 
operation,  we  should  have  to  divide  the  tendon  of  the  internal  rectus 
muscle  of  this  eye  to  such  an  extent  that  the  muscle  might  recede  4^'". 
This  would  be,  however,  accompanied  by  a  diminution  in  the  mobility 
inwards  of  about  5^'"  ;  and  even  supposing  that  the  pathological 
increase  in  the  mobility  in  this  direction  had  been  previously  about  one 
line,  we  should  still  have  a  deficiency  of  about  4^'"  after  the  operation. 
The  associated  movements  towards  the  left  side  of  the  patient  would, 
therefoi-e,  be  greatly  impeded  ;  and  this  want  of  mobility  inwards  would 
make  itself  particularly  felt  during  the  accommodative  movements,  for 
it  would  prevent  the  proper  convergence  of  the  optic  axes  during  reading, 
etc.,  as  the  optic  axis  of  the  right  eye  would  deviate  slightly  outwards 
from  the  object,  and  this  divergent  squint  would  soon  increase  in  extent 
and  become  permanent.  In  order  to  obviate  this,  we  must  divide  the 
operation  between  the  two  eyes.  Let  us  suppose  that  the  tenotomy  of 
the  right  internal  rectus  has  corrected  2|-"'  of  the  deviation,  there  will, 
consequently,  still  remain  an  inward  squint  of  this  eye  of  about  2  lines. 
On  covering  the  left  eye  with  our  hand,  and  telling  the  patient  to  look 
at  the  object  with  the  right,  the  latter  will  have  to  make  an  outward 
movement  of  2'",  and  this  will  be  accompanied  by  an  inward,  associated 
movement  of  the  left  eye  of  the  same  extent.  We  must  now  calculate 
the  ejftent  of  the  operation  which  will  be  necessary  to  correct  the 
secondary  squint  of  the  left  eye,  just  as  if  the  latter  were  primarily 
affected  with  a  convergent  squint  of  2'".  Let  us  now  assume  that  the 
left  internal  rectus  has  been  divided,  and  that  we  have  obtained  an 
effect  of  2'",  the  eye  will,  consequently,  incline  outwards  to  this  extent, 
a  divergent  squint  of  2'"  being  in  fact  produced ;  and  it  will,  therefore, 
require  an  extra  exertion  of  the  internal  rectus  to  bring  the  optic  axis 
of  the  left  eye  to  bear  again  upon  the  object.  Now,  this  inward  move- 
ment of  2'"  will  be  accompanied  by  an  associated  outward  movement 
of  the  right  eye  to  the  same  extent ;  hence,  the  convergent  squint 
which  had  remained  after  the  first  operation  will  be  completely  cor- 
rected. If  binocular  vision  exists,  the  double  images  will  now  be  so 
very  closely  approximated,  that  a  very  slight  muscular  effort  will  be 
able  to  unite  them  permanently,  and  the  cure  of  the  squint  will  be 
perfect. 

The  operation  is  always  to  be  performed  in  such  a  manner,  that  the 


\ 


TREATMENT   OF   STRABISMUS.  587 

greater  amount  of  correction  is  apportioned  to  tlie  squinting  eye,  as 
the  mobility  is  pathologically  increased  in  the  directioia  of  the  shortened 
muscle. 

I  shall  confine  my  description  to  three  operations,  viz. :  Von  Graefc's, 
the  subconjunctival  operation  of  Mr.  Critchett,  and  Liebreich's  modi- 
fication of  Graefe's  operation. 

I  may  mention,  however,  that  the  old  operation,  in  which  the  con- 
junctiva and  subconjunctival  tissue  were  widely  incised,  the  capsule  of 
Tenon  lacerated,  the  muscle  itself,  and  not  its  tendon,  divided,  should 
never  be  performed.  Its  effect  is  generally  most  unhappy,  and  it 
brought  the  operation  for  strabismus  into  great  disrepute. 

The  principle  of  Von  Graefe's  operation  consists  in  a  very  careful 
division  of  the  tendon  close  to  its  insertion ;  with  the  smallest  possible 
amount  of  laceration  of  the  subconjunctival  tissue,  and  the  tendinous 
processes  of  the  capsule  of  Tenon.  "We  diminish  the  power  of  the 
muscle  by  giving  it  a  more  backward  insertion ;  but  we,  at  the  same 
time,  preserve  its  length  intact.  Our  object  is  only  to  weaken  the 
muscle,  and  not  to  render  it  more  or  less  impotent.  Before  proceeding 
to  consider  this  method  of  operating,  I  would,  however,  dwell  for  a 
moment  upon  the  anatomical  relations  of  the  muscles  of  the  eye  with 
the  ocular  sheath.  Commencing  at  the  optic  foramen  and  loosely  em- 
bracing the  optic  nerve,  the  sheath  expands,  and  passes  on  to  the  eye- 
ball, which  it  encloses.  It  is  loosely  connected  with  the  sclerotic  by 
connective  tissue — so  loosely,  indeed,  as  to  allow  of  the  free  rotations 
of  the  globe  within  it.  At  the  equator  of  the  eyeball,  it  is  pierced  by 
the  tendons  of  the  oblique  muscles,  and,  more  anteriorly,  by  the  tendons 
of  the  four  recti  muscles,  with  which  it  becomes  blended ;  being  finally 
lost  on,  rather  than  inserted  into,  the  sclerotic,  close  to  the  cornea.  The 
posterior  portion  of  the  sheath,  up  to  the  passage  of  the  tendons,  has 
been  called  the  capsule  of  Bonnet ;  the  anterior  portion,  from  the 
passage  of  the  tendons  to  its  insertion  in  the  sclerotic,  having  been 
designated  the  capsule  of  Tenon.  On  piercing  the  capsule,  the  tendons 
of  the  recti  muscles  become  connected  with  it  by  slight  cellular  pro- 
cesses, sent  forth  from  the  capsule.  These  processes  prevent  the  too 
great  retraction  of  the  muscle  after  the  division  of  its  tendon,  which 
would  be  followed  by  a  great  loss  of  power.  It  is,  therefore,  of 
much  consequence,  that  these  connecting  processes  should  not  be 
severed  by  the  tendon  being  divided  too  far  back,  or  be  lacerated  by 
rude  and  careless  manipulations  with  the  strabismus  hook.  Von  Graefe 
has,  moreover,  pointed  out  that  the  result  may  be  u.nfavourable,  even 
although  the  tendon  has  been  divided  anterior  to  these  fibres,  as  the 
sheath  of  the  tendon  becomes  thickened  from  the  point  at  which  it 
passes  tkrough  the  capsule,  and  this  thickening  extends  nearly  up  to 
its  insertion.     If  the  tendon  is,  therefore,  not  divided  sufiiciently  close 


588 


AFFECTIONS   OF   THE   MUSCLES   OF   THE   EYE. 


to  its  insertion,  it  is  apt  to  retract  witliin  this  thickened  sheath,  and 
this  retraction  will  in  many  cases  prevent  its  reunion  with  the  sclerotic. 
In  the  old  operation,  the  muscle  was  divided  far  back,  frequently  even 
posterior  to  its  passage  through  the  capsule,  and  it  was  consequently 
often  rendered  so  powerless,  that  the  eyeball  could  not  be  moved  in 
this  direction ;  its  opponent  acquired  a  corresponding  preponderance  of 
power,  giving  but  too  frequently  rise  to  a  secondary  squint  in  the 
opposite  direction.  Hence  the  popular  dread  of  the  operation,  "  lest 
the  eye  should  go  the  other  way."  But  such  an  unfortunate  result  is 
not  to  be  feared  if  the  surgeon  performs  the  operation  with  care  and 
circumspection,  and  is  thoroughly  conversant  with  the  theoretical  part 
of  the  subject.  It  is  an  important  rule  never  to  do  too  much,  for 
nothing  is  so  difficult  as  to  retrace  one's  steps  and  to  patch  up  a  fault 
which  has  been  committed.  It  is  far  easier  subsequently  to  increase 
the  effect  of  the  operation,  than  to  diminish  it.  I  know  of  no  surgical 
operation  which  is  so  safe  and  so  sure  in  its  cure  as  that  for  strabismus, 
when  properly  performed.  Let  us  now  pass  on  to  the  description 
of  Von  Graefe's  operation. 

As  it  is  sometimes  very  painful,  the  patient  should  be  placed  under 
the  influence  of  chloroform.  The  eyelids  are  to  be  kept  apart  by  the 
spring  speculum,  or,  if  this  proves  not  sufficiently  strong,  by  the  broad 
silver  elevators.  An  assistant  should  evert  the  eye  with  a  paii'  of 
forceps  (I  am  supposing  that  the  internal  rectus  of  the  right  eye  is  to 
be  operated  on),  taking  care  to  do  so  in  the  horizontal  direction,  with- 
out rotating  the  eyeball  on  its  axis ;  otherwise,  the  horizontal  position 
of  the  internal  rectus  will  be  changed.  The  operator  should  then 
seize,  with  a  pair  of  finely-pointed  forceps,  a  small,  but  deep  fold  of  the 
conjunctiva  and  subconjunctival  tissue,  close  to  the  edge  of  the  cornea, 
and  about  midway  between  the  centre  and  lower  edge  of  the  insertion 
of  the  internal  rectus.  He  next  snips  this  fold  with  the  scissors  (which 
should  be  bent  on  the  flat,  and  blunt  pointed),  and,  buiTow- 
ing  beneath  the  subconjunctival  tissue  in  a  downward  and 
inward  direction,  makes  a  funnel-shaped  opening  beneath 
the  subconjunctival  tissue,  this  being,  however,  done  very 
carefully,  so  as  not  to  divide  it  to  too  great  an  extent.  If  the 
subconjunctival  tissue  is  thick  and  strong,  it  will  be  better 
first  to  take  up  a  small  fold  of  the  conjunctiva  only,  to  open 
this,  and  then,  seizing  the  subconjunctival  tissue,  to  divide 
the  latter.  The  squint-hook  (which  should  be  bent  at  a  right 
angle,  and  have  a  slightly  bulbous  point,  vide  Fig.  82)  is  then 
to  be  passed  through  the  opening  to  the  lower  edge  of  the 
tendon.  Its  point  being  pressed  somewhat  firmly  against  the 
sclerotic,  the  hook  is  to  be  turned  on  the  point  and  slid  up- 
wards beneath  the  tendon,  as  close  to  its  insertion  as  possible, 


Fig.  82. 


TREATMENT   OF   STRABISMUS.  589 

and  the  whole  expanse  of  the  tendon  caught  up.  The  operator  must 
be  careful  not  to  direct  the  point  of  the  hook  upwards  and  outwards, 
otherwise  it  may  perforate  the  fibres  of  the  tendon,  and  only  a  portion 
of  the  latter  be  caught  up ;  the  direction  of  the  point  should,  there- 
fore, be  rather  upwards  and  inwards.  When  the  tendon  has  been 
secured  on  the  hook,  the  conjunctiva  which  covers  its  upper  portion 
may  be  gently  pushed  off  with  the  points  of  the  scissors,  so  as  to  expose 
the  tendon,  which  is  then  to  be  carefully  snipped  through  with  the 
scissors  as  closely  as  possible  to  its  insertion.  When  it  has  been  com- 
pletely cut  through,  the  conjunctiva  is  to  be  slightly  elevated  on  the 
point  of  the  hook,  and  a  smaller  hook  passed  upwards  and  downwards 
to  ascertain  Avhether  the  lateral  expansions  of  the  tendon  have  been 
divided.  Should  a  few  fibres  remain,  they  must  be  divided,  and  the 
surgeon  should  again  ascertain  whether  any  others  are  still  present. 
He  should  never  omit  to  satisfy  himself  upon  this  point,  for  sometimes 
the  lateral  expansions  are  considerable,  the  tendon  spreading  out  like 
a  fan,  and  although  a  few  fibres  only  might  remain  undivided,  they 
would  sufiice  to  spoil  the  effect  of  the  operation. 

I  have  lately  adopted  a  slight  modification  of  Von  Graefe's  operation, 
and  perform  it  more  subconjunctivally.  I  use  a  pair  of  straight 
blunt-pointed  scissors,  and,  instead  of  pushing  off  the  conjunctiva  from 
the  hook  so  as  to  expose  the  tendon  caaght  up  by  the  latter,  I  divide 
the  tendon  subconjunctivally,  quite  close  to  its  insertion.  In  this  way, 
the  advantages  of  Graefe's  and  the  subconjunctival  operation  are  com- 
bined. On  account  of  the  smaller  size  of  the  hook,  and  the  situation 
of  the  incision  (which  is  between  the  centre  and  lower  edge  of  the 
tendon),  the  subconjunctival  tissue  is  stretched  and  incised  to  a  much 
less  extent  than  in  the  subconjunctival  operation.  Again,  the  position 
and  direction  of  the  conjunctival  wound  are  such  that  a  suture  can  be 
at  once  applied,  if  necessary  ;  whereas,  in  the  subconjunctival  opera- 
tion the  incision  would  have  to  be  considerably  enlarged  upwards, 
before  any  effect  C(juld  be  produced  by  a  suture  upon  the  two  cut  edges 
of  the  tendon.  But  where  the  degree  of  strabismus  is  so  considerable 
that  it  is  certain  no  suture  will  be  required,  the  subconjunctival  operation 
may  be  employed ;  and  also  if  we  have  no  assistant  at  hand  to  roll  the 
eye  in  the  opposite  direction. 

If  it  is  found,  on  the  first  introduction  of  the  hook,  that  this  shdes  up 
to  the  edge  of  the  cornea  without  having  caught  up  the  tendon,  it  is 
certain  that  we  have  either  not  divided  the  subconjunctival  tissue  at  all, 
or  that  the  hook  has  been  passed  between  it  and  the  conjunctiva.  If 
the  former  is  the  case,  we  must  open  the  subconjunctival  tissue,  and 
then,  on  re-introducing  the  hook,  we  shall  have  no  difficulty  in  finding 
the  tendon.  The  opening  in  the  conjunctiva  and  subconjunctival  tissue 
should  be  but  small,  and  the  excursions  with  the  hook  limited,  other- 


590       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

wise,  the  subconjunctival  tissue  and  the  lateral  processes  of  the  capsule 
of  Tenon  will  be  extensively  lacerated,  which  may  be  followed  by  too 
great  a  recession  of  the  muscle. 

The  after-treatment  is  very  simple.  The  eye,  after  having  been  well 
washed  and  cleansed  of  any  blood  coagula,  is  to  be  kept  constantly 
moist  with  cold  water_^dressing  during  the  day  of  operation,  so  as  to 
prevent  any  extensive  effusion  of  blood  under  the  conjunctiva.  No 
button  of  granulations  will  form  on  the  stump  of  the  tendon,  if  the 
latter  has  been  divided  close  to  its  insertion,  and  if  the  opening  in  the 
conjunctiva  has  been  made  near  the  upper  or  lower  edge  of  the  tendon, 
so  as  not  to  leave  the  latter  exposed. 

The  effect  upon  the  squint  which  follows  immediately  upon  the 
operation,  will  not  be  the  permanent  one.  We  may,  indeed,  distinguish 
three  stages  in  the  effect  produced  by  the  operation  : — 1st.  The  period 
immediately  following  the  operation  ;  2nd.  After  three  or  four  days  have 
elapsed ;  3rd.  After  the  interval  of  a  few  months, — this  being  the  per- 
manent effect.  Dulling  the  first  stage,  the  effect  will  be  considerable,  for 
the  eye  can  now  only  be  moved  in  the  direction  of  the  divided  muscle 
by  the  indirect  connexion  of  the  latter  with  the  sclerotic  by  the  lateral 
processes  of  the  capsule  of  Tenon.  As  soon  as  the  divided  end  of  the 
tendon  becomes  reunited  with  the  sclerotic,  which  generally  occurs 
within  three  or  four  days,  the  effect  will  diminish,  for  the  muscle  now 
again  exerts  a  direct  influence  upon  the  eyeball.  This  is  the  second 
stage.  But  we  find  that  a  fui-ther  alteration  in  the  position  generally 
shows  itself  a  few  weeks  or  months  after  the  operation,  the  effect  being- 
then  again  somewhat  increased.  This  is  due  to  the  action  of  the 
opponent  muscle,  which,  on  account  of  its  antagonist  having  been 
weakened,  can  now  exei-t  a  greater  influence  upon  the  position  of  the 
eyeball. 

A  clue  to  the  permanent  result  of  the  operation  is  furnished  by  the 
position  of  the  operated  eye  during  the  accommodative  movements  of 
the  eyes,  when  they  are  directed  upon  some  near  object.  It  is,  there- 
fore, of  great  consequence  always  to  test  the  position  of  the  eyes 
during  accommodation  immediately  after  the  operation,  as  soon  as  the 
effect  of  the  chloroform  has  gone  off.  We  have  already  seen  that  the 
position  of  the  squinting  eye  (convergent  strabismus)  may  vary  when 
tlie  object  is  approximated  closely  to  the  eyes  ;  for  whilst  the  optic  axis 
of  the  healthy  eye  remains  fixed  upon  the  object,  converging  the  more 
the  nearer  the  latter  is  brought,  the  position  of  the  squinting  eye  may 
undergo  the  following  changes  : — 1st.  It  may  retain  its  original  position, 
sustaining  only  a  few  oscillating,  iiTegular,  lateral  movements.  2nd. 
It  may  remain  completely  stationary,  so  that  the  angle  of  squinting  will 
dimijiish  the  more  the  nearer  the  object  is  brought,  until,  at  a  certain 
point  (if  the  squint  be  not  excessive),  its  optic  axis  will  also  be  fixed 


TREATMExNT   OF   STRABISMUS.  591 

upon  the  object,  and  tlicre  will  no  loug-er  be  any  squint.  If,  liowcver, 
the  object  is  approximated  still  closer,  a  divergent  squint  will  arise  ;  for 
whilst  the  healthy  eye  converges  still  more,  the  other  retains  its  position, 
and  now  deviates  (passively)  outwards.  3rd.  It  retains  its  position  up 
to  a  certain  point,  and  then,  as  the  healthy  eye  moves  inwards  to  follow 
the  object,  it  makes  an  associated  movement  outwards.  4th.  It  deviates 
suddenly  and  spasmodically  inwards  when  the  object  is  very  closely 
approximated. 

We  should,  therefore,  soon  after  the  operation,  when  the  effect  of 
the  chloroform  has  passed  off,  ascertain  whether  both  optic  axes  can  be 
steadily  fixed  upon  the  object,  when  it  is  brought  to  a  distance  of  from 
four  to  six  inches  from  the  eyes  (their  state  of  refraction  being  normal). 
If  the  eyes  are  very  short-sighted,  the  distance  should  be  still  less. 
The  final  result  of  the  operation  may  be  predicted  from  the  position 
which  the  operated  eye  now  assumes.  If  it  remains  stationary  when 
the  object  is  brought  up  to  within  eight  inches  from  the  eyes,  so  that  a 
passive  divergence  will  arise  on  its  being  approximated  still  closer,  we 
must  expect  a  certain  amount  of  divergence  in  the  course  of  a  few 
months.  But  this  will  be  still  more  the  case,  if  the  eye,  instead  of 
simply  remaining  stationary,  makes  an  associated  movement  outwards. 
It  is  necessary  to  test  this  at  short  distances  (four  or  six  inches),  for 
the  eye  might  be  able  momentarily  to  fix  its  optic  axis  upon  the 
object,  although  quite  incapable  of  maintaining  this  position  for  any 
length  of  time.  In  both  the  above  cases,  the  effect  of  the  operation  is 
to  be  diminished  by  a  conjunctival  suture,  and  particularly  so  in  the 
latter  instance.  The  effect  of  the  suture  will  vary  with  its  position,  and 
WT.th  the  amount  of  the  conjunctiva  embraced  in  it.  Its  effect  will  be 
considerable  if  it  be  inserted  in  a  diagonal  direction  from  downwards  and 
inwards  to  upwards  and  outwards,  so  that  the  inner  and  outer  lips  of 
the  wound  are  united.  By  giving  it  this  direction,  we  also  prevent  any 
sinking  of  the  caruncle.  The  suture  diminishes  the  effect  of  the  opera- 
tion by  re-advancing  the  tendon,  which  is  closely  connected  with  the 
conjunctiva  and  subconjunctival  tissue  ;  the  divided  ends,  consequently, 
will  be  more  closely  approximated,  and  the  retraction  of  the  muscle 
diminished.     The  suture  may  remain  in  for  from  24  to  36  hours. 

The  fourth  position  which  the  operated  eye  may  assume  during 
accommodation,  viz.,  making  a  sudden  spasmodic  movement  inwards, 
must  make  us  fear  that  there  will  be  a  relapse — that  in  the  course  of  a 
few  months  the  inward  squint  will  again  show  itself;  for  this  conver- 
gent squint,  which  at  first  only  showed  itself  duinng  accommodation 
for  near  objects,  will  gradually  extend  also  to  greater  distances.  In 
such  cases,  the  operation  is  said  to  have  been  only  of  temporary  benefit ; 
we  should  therefore,  at  once  intimate  to  the  friends  of  the  patient  that 
the  squint  may  return,  and  necessitate  another  operation. 


592       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

The  extent  of  the  operation  must  be  regnlated  accorduig  to  the 
degree  of  the  squint. 

In  very  shght  degrees  of  strabismus  (1  to  1^'")  a  partial  tenotomy 
was  formerly  often  practised,  the  tendon  not  being  completely  divided, 
but  a  few  of  the  upper  or  lower  fibres  (as  the  case  might  be)  being 
left  standing.  But  this  does  not  answer,  as  the  power  of  the  muscle  is 
but  slightly,  if  at  all,  impaired.  In  such  cases,  we  should,  therefore,  make 
a  complete  tenotomy  and,  if  necessary,  insert  a  suture.  The  conjunctival 
opening  should  be  small  and  the  hook  but  of  modei^ate  size.  The  accom- 
m.odative  movements  must  be  accurately  tested  immediately  after  the 
operation ;  for,  if  there  is  the  slightest  tendency  to  divergence  when  the 
object  is  brought  up  to  8  or  6  inches  from  the  eye,  a  suture  should  be 
inserted.  In  a  squint  of  2  or  2|  lines,  the  cellular  tissue  may  be  somewhat 
more  freely  incised,  and  a  larger  hook  employed.  In  children,  we  find  that 
the  efiect  is  generally  more  considerable,  for  the  muscle  is  not  hypertro- 
phied  and  the  surrounding  cellular  tissue  is  very  elastic;  we  may,  there- 
fore, in  them  easily  attain  an  effect  of  2^-  or  3  lines  by  a  single  operation. 

If  the  squint  exceeds  2|  or  3  lines,  we  must  always  operate  upon 
both  eyes.  We  should  perform  a  free  tenotomy  in  the  squinting  eye  and 
a  very  careful  one  in  the  other,  greatly  limiting  the  effect  in  the  latter 
by  a  suture.  In  this  we  must  be  guided  by  the  amount  of  squint  left 
after  the  affected  eye  has  been  operated  upon.  As  a  general  rule,  I  do 
not  think  it  advisable  to  operate  upon  both  eyes  at  the  same  time, 
except  the  squint  is  very  considerable,  exceeding  4-1-  or  5  lines.  For  if 
both  muscles  have  been  divided  at  the  same  time,  we  cannot  accurately 
test  the  accommodative  movements  directly  after  the  operation,  and  we 
thus  lose  the  only  clue  to  the  permanent  effect.  It  is,  therefore,  far 
safer  to  operate  first  upon  the  affected  eye,  and  then,  after  a  few  days 
have  elapsed,  and  the  divided  tendon  has  again  reunited  with  the  scle- 
rotic, to  ascertain  how  much  of  the  squint  is  still  left.  The  amount  still 
remaining  will  guide  us  as  to  the  extent  of  the  operation  necessary  upon 
the  healthy  eye.  If,  after  having  operated  upon  the  latter,  we  find  that 
the  effect  somewhat  exceeds  our  wishes,  we  can  always  diminish  it  by  a 
suture.  It  certainly  is  far  more  brilliant  to  operate  upon  both  eyes  at 
the  same  time,  and  thus  rid  the  patient  at  once  of  the  squint,  but  then 
we  run  the  risk  of  the  unpleasant  contingency  of  the  eye  subsequently 
"  going  the  other  way."  It  should  always  be  remembered  that  the  cure 
is  to  be  permanent,  and  not  temporary.  In  some  exceptional  cases, 
however,  the  risk  must  be  run — if  for  instance,  the  time  of  the  patient 
is  limited,  or  a  second  visit  impossible.  If  the  squint  exceeds  five  lines, 
we  may,  particularly  in  adults,  operate  safely  upon  both  eyes  at  the 
same  time.  It  may  be  occasionally  necessary  to  operate  not  only  upon 
both  eyes,  but  even  to  repeat  the  operation  upon  the  squinting  eye, 
before  wc  can  cure  the  affection.    This  generally  occurs  only  in  cases  of 


TREATMENT   OF   STRABISMUS.  593 

excessive  squint,  or  if  the  sti-abismus  has  existed  for  a  long  time,  and 
the  muscle  has  become  hj'pei-trophied.  This  second  operation  upon  the 
affected  eye  requires  considerable  care,  for  the  effect  of  the  correction 
will  exceed  the  extent  of  the  reti-action,  as  the  influence  of  the  muscle 
upon  the  eyeball  diminishes  in  proportion  to  the  backward  position  of 
its  insertion. 

In  severe  cases,  it  is  still  better  to  operate  first  upon  the  squinting 
eye,  and  to  increase  the  effect  as  much  as  possible  by  making 
the  patient  look  over  to  the  opposite  side  for  some  days  after  the  ope- 
ration, so  that  the  cut  edges  of  the  tendon  may  be  stretched  apart,  and 
widely  separated.  The  effect  of  this  will  be,  that  the  union  will  take 
place  further  back  than  would  have  occurred  if  the  eye  had  maintained 
a  median  position.  If  the  internal  rectus  of  the  right  eye  has  been 
divided,  and  we  desire  to  increase  the  effect  of  the  operation,  the  patient 
should  be  directed  to  look,  as  far  as  possible,  towards  his  right  side. 
The  easiest  way  of  attaining  this  is,  by  jnaking  the  patient  wear  spec- 
tacles, the  left  half  of  each  glass  being  covered  with  a  piece  of  court 
plaister,  for  he  will  in  tliis  way  be  obliged  to  look  to  the  right.  They 
should  be  worn  dui'ing  the  first  three  or  four  days  after  the  operation. 
Or  two  pieces  of  card  may  be  fixed  over  the  left  half  of  the  eyes,  by 
means  of  a  tape  passing  over  the  forehead.  By  this  means,  we  shall 
obtain  a  very  considerable  effect  by  the  operation,  and  the  amount  of 
squint  still  remaining,  must  then  be  treated  by  an  operation  upon  the 
other  eye. 

Von  Graefe  points  out  the  fact  that,  occasionally,  though  rarely,  we 
meet  with  cases  in  which  the  operation  is  followed  by  no  effect,  either 
upon  the  position  or  mobility  of  the  eyeball,  and  yet  no  lateral  fibres  of 
the  tendon  have  remained  undivided.  In  such  cases,  there  is  a  second 
connexion  of  the  muscle  with  the  sclerotic  further  back,  near  the  equa- 
tor ;  in  one  instance,  indeed,  he  found  it  even  posterior  to  the  equator. 

If  the  operation  for  squint  be  carefully  performed,  there  is  no  fear 
of  any  but  the  slightest  sinking  of  the  caruncle.  A  little  sinking  will 
occasionally  occui%  whatever  mode  of  operation  be  employed  ;  indeed,  I 
know  of  no  method  which  can  guarantee  a,  perfect  immunity  from  it. 
Von  Graefe  thinks  that  the  sinking  does  not  depend  so  much  upon  the 
gaping  of  the  conjunctival  wound  and  retraction  of  its  inner  lip,  as 
upon  the  cicatrization  of  the  connective  tissue  situated  between  the 
muscle  and  conjunctiva,  by  which  the  moveable  caruncle  is  retracted. 
The  further  back  this  cicati'ization  extends,  the  more  will  the  caruncle 
sink.  Hence,  the  danger  of  incising  the  tendon  too  freely,  and  of  any 
considerable  sweeping  about  with  the  hook,  and  consequent  extensive 
laceration  of  the  subconjunctival  tissue. 

Mr.   Critchett's  subconjunctival  operation    is   to  be  performed  as 
follows  : — The  patient  having  been  placed  under  the  influence  of  chlo- 

2  Q 


594 


AFFECTIONS   OF   THE   MUSCLES   OP   THE  EYE. 


Fig.  83. 


roform,  and  the  eyelids  kept  apart  by  the  stop  speculum,  he  seizes  a 
small  fold  of  the  conjunctiva  and  subconjunctival  tissue  at  the  lower 
edge  of  the  insertion  of  the  rectus  muscle,  and  with  a  pair  of  blunt 
pointed  straight  scissors,  makes  a  small  incision  at  this 
point  through  these  structures.  The  lower  edge  of  the 
tendon,  close  to  its  insertion,  is  now  exposed.  A  blunt 
hook  (Fig.  83)  is  next  to  be  passed  through  the  open- 
ing in  the  subconjunctival  tissue  beneath  the  tendon, 
so  as  to  catch  up  the  latter,  and  render  it  tense.  The 
points  of  the  scissors  (but  slightly  opened)  are  then 
to  be  introduced  into  the  aperture,  and  one  point  passed 
along  the  hoo"k  behind  the  tendon,  the  other  in  front 
of  the  tendon  between  it  and  the  conjunctiva,  and  the 
tendon  is  then  to  be  divided  close  to  its  insertion  by 
successive  snips  of  the  scissors.  A  small  counter  punc- 
ture may  be  made  at  the  upper  edge  of  the  tendon  to 
permit  of  the  escape  of  any  effused  blood,  and  thus 
prevent  its  diffusion  beneath  the  conjunctiva  (Bowman). 
Dr.  Liebreich*  has  lately  introduced  a  modification  of  the  operation 
of  strabismus,  based  upon  a  different  view  of  the  anatomical  relations 
of  the  conjunctiva,  subconjunctival  tissue,  and  the  capsule  of  Tenon  to 
the  muscles  of  the  eye.  He  considers  the  capsule  of  Tenon  as  divided 
into  two  portions — an  anterior  and  a  posterior — the  division  being 
formed  at  the  point  where  the  recti  muscles  pierce  it  from  without 
inwards ;  the  capsule  being  at  this  point  so  closely  connected  with  the 
muscles,  as  to  render  any  displacement  between  the  two  impossible. 
The  poster-ior  half  of  the  capsule,  with  its  smooth,  firm,  inner  surface, 
forms  a  cup,  in  which  the  eyeball  moves  freely  as  the  head  of  a  joint  in 
the  socket.  The  close  connection  between  the  muscles  and  the  pos- 
terior half  of  the  capsule  is  increased  by  sheath-like  processes,  which 
run  backwards  from  the  outer  sui'face  of  the  capsule  towards  the  orbit, 
and  which  are,  for  a  certain  distance,  closely  connected  with  the 
muscles.  Bat  there  are  no  sheath- like  processes  between  the  inner 
portion  of  the  posterior  capsule  and  the  sclerotic.  The  anterior  half 
of  the  capsule  of  Tenon  adheres  to  the  upper  surface  of  the  muscle,  and 
is  intimately  connected  with  it.  But  Liebreich  denies  the  presence  of 
sheath-like  processes  derived  from  the  capsule,  where  they  pierce  the 
latter,  and  accompanying  the  muscles  as  far  as  their  insertion.  He 
states,  moreover,  "  That  the  caruncle,  together  with  the  semilunar  fold 
rest  upon  a  band-like  ligament,  which  passes  from  the  capsule  of 
Tenon  towards  the  edge  of  the  orbit.  Now  when  the  internal  rectus  is 
contracted,  and  the  eye  rolled  inwards,  this  band  is  rendered  tense ; 


*  "  A.  f.  O.,"  xii,  2,  298  ;  also  "Eritish  Medical  Journal,"  Dec.  15,  1866. 


TREATMENT   OF   STRABISMUS.  595 

and  the  caruncle,  which  is  fixed  to  it,  is  consequently  drawn  in  towards 
the  inner  edge  of  the  orbit.  But  the  outer  edge  of  the  caruncle, 
together  with  the  semilunar  fold,  and  an  adjoining  portion  of  con- 
junctiva are  drawn  backwards  into  a  furrow. "  This  intimate  connection 
between  the  muscle,  capsule,  and  caruncle,  is  the  reason  of  the  sinking 
of  the  caruncle  and  semilunar  fold,  which  is  occasionally  observed,  after 
an  extensive  division  of  the  internal  rectus.  To  obviate  these  disad- 
vantages, and  yet  to  obtain  a  considerable  effect,  Liebreich  operates  in 
the  following  manner : — 

"  If  the  mternal  rectus  is  to  be  divided,  I  raise  with  a  pair  of  forceps 
a  fold  of  conjunctiva  at  the  lower  edge  of  the  insertion  of  the  muscle ; 
and,  incising  this  vrith  scissors,  enter  the  points  of  the  latter  at  the 
opening  between  the  conjunctiva  and. the  capsule  of  Tenon.  I  then 
carefully  separate  these  two  tissues  from  each  other  as  far  as  the  semi- 
lunar fold,  also  separating  the  latter,  as  well  as  the  caruncle,  from  the 
parts  lying  behind.  "When  this  portion  of  the  capsule,  which  is  of  such 
importance  in  the  tenotomy,  has  been  completely  separated  from  the 
conjunctiva,  I  divide  the  insertion  of  the  tendon  from  the  sclerotic  in 
the  usual  manner,  and  extend  the  vertical  cut,  which  is  made  simul- 
taneously with  the  tenotomy,  upwards  and  downwards — the  more  so  if 
a  very  considerable  effect  is  desu'ed.  The  wound  in  the  conjunctiva  is 
then  closed  with  a  suture. 

"  The  same  mode  of  operating  is  to  be  pursued  in  dividing  the 
external  rectus ;  and  the  separation  of  the  conjunctiva  is  to  be  con- 
tinued as  far  as  that  portion  of  the  external  angle  which  is  drawn 
sharply  back  when  the  eye  is  tui'ned  outwards. 

"  The  following  are  the  advantages  of  my  proceeding:—' 
"1.  It  affords  the  operator  a  greater  scope  in  apportioning  and 
dividing  the  effect  of  the  operation  between  the  two  eyes. 

"  2.  The  sinking  back  of  the  carujicle  is  avoided,  as  well  as  every 
trace  of  a  cicatrix,  which  not  unfrequently  occurs  in  the  common 
tenotomy. 

"  3.  There  is  no  need  for  more  than  two  operations  on  the  same 
individual,  and  therefoi-e  of  more  than  one  on  the  same  eye." 

I  have  performed  Liebreich' s  operation  in  numerous  instances  with 
much  success,  and  should  prefer  it  to  any  other  in  those  cases  in  which 
it  was  desirable  to  gain  a  very  considerable  effect,  and  yet  confine  the 
operation  to  one  eye.  For  I  have  not  found  that  we  are  able  by  any 
other  operation  to  obtain  so  considerable  an  efiect  with  so  slight  a  loss 
of  mobility,  and  so  very  little  (if  any)  sinking  of  the  caruncle  ;  yet  the 
inadmissibility  of  chloroform  and  the  insertion  of  the  sutures  have 
prevented  my  practising  this  operation  extensively.  If  chloroform  is 
given,  we  cannot  estimate  with  exactitude  the  degree  of  effect  which 
we  are  producing  by  the  free  incisions  in  the  capsule ;  and  but  few 

2  Q  2 


596  AFFECTIONS   OF   THE  MUSCLES   OF   THE  EYE. 

patients  are  willing  to  submit  to  a  rather  lengthened  and  painful 
operation,  unless  chloroform  is  administered.  The  removal  of  the 
sutures  a  day  or  two  after  the  operation  is  frequently  attended  with  a 
good  deal  of  difficulty  in  children  and  nervous  hysterical  women,  for 
although  the  proceeding  is  quite  painless,  yet  it  is  often  regarded  by 
the  patient  and  his  friends  as  a  second  operation.  Where  it  is  abso- 
lutely necessary  for  the  success  of  the  operation  to  insert  a  suture,  I 
never  hesitate  to  do  so,  but  in  Graefe's  operation  this  is  the  exception, 
whereas,  in  Liebreich's  it  is  the  rule. 

I  must  now  describe  the  method  in  which  certain  special  forms  of 
strabismus  should  be  treated.  The  question  sometimes  arises,  whether 
the  periodic  squint  which  is  caused  by  hypermetropia  should  be  ope- 
rated on,  or  whether  it  is  to  be  corrected  by  the  use  of  suitable  convex 
glasses.  If  it  is  but  slight  in  extent,  glasses  may  suflB.ce,  but  if  it  is 
considerable,  and  the  internal  rectus  is  very  strong,  tenotomy  should 
be  performed ;  for  by  dividing  the  internal  rectus,  we  diminish  its 
power,  and  a  greater  exertion  of  this  muscle  will  consequently  be 
demanded,  in  order  to  bring  the  optic  axis  to  bear  again  upon  the 
object.  This  extra  exertion  will  be  accompanied  by  an  increased 
power  of  accommodation,  as  was  the  case  before,  when  the  eye  squinted. 
But  we  shall  now  have  an  increased  power  of  accommodation  with  a 
normal  position  of  the  optic  axes. 

On  examining  such  cases  of  periodic  squint  with  prisms,  we  gene- 
rally find  that  the  internal  recti  muscles  are  abnormally  strong,  this 
preponderance  in  strength  extending  throughout  the  whole  field  of 
vision,  so  that  the  correct  position  of  the  optic  axes,  which  may  occur 
when  convex  glasses  are  interposed,  is  frequently  forced.  A  carefully 
performed  tenotomy  of  the  internal  rectus  muscle  is,  consequently, 
productive  of  very  favourable  results.  By  advising  an  operation  for 
this  form  of  periodic  squint,  I  do  not  propose  to  set  aside  the  use  of 
convex  glasses  for  the  treatment  of  the  hypermetropia ;  I  only  think  it 
beneficial  to  balance  the  strength  of  the  muscles  of  the  eyeball,  and  to 
restore  their  normal  equilibrium,  for  this  will  be  accompanied  by 
increased  facility  and  comfort  in.  the  use  of  the  eyes,  particularly  for 
prolonged  work  at  near  objects.  Whether  or  not  both  eyes  will  require 
to  be  operated  on,  will  depend  upon  the  amount  of  the  squint,  and  the 
relative  strength  of  the  internal  recti  muscles. 

I  believe  that  the  best  treatment  for  this  form  of  periodic  squint 
consists  in  a  careful  tenotomy  of  the  internal  rectus,  with  subsequent 
neutralization  of  the  hypermetropia  by  means  of  convex  glasses.  In 
some  cases,  the  question  may,  however,  arise,  whether,  by  operating 
upon  the  periodic  squint,  we  may  not  only  free  the  patient  from  the 
deformity,  but  also  obviate  the  necessity  for  spectacles ;  for,  after  the 


TREATMENT   OF   STRABISMUS.  597 

operation,  the  increased  exertion  of  the  accommodation  in  reading,  etc., 
will  be  unaccompanied  by  a  squint.  This  question  arises  chiefly  with 
ladies,  who  desire  not  only  to  be  freed  from  the  squint,  but  also  from 
the  necessity  of  wearing  spectacles. 

The  periodic  squint  which  occurs  in  the  short-sighted,  generally 
only  shows  itself  when  the  object  is  removed  beyond  the  range  of 
accommodation.  As  this  squint  disappears  as  soon  as  the  myopia  is 
neutralized  by  the  proper  concave  glasses,  it  might  appear  unnecessary 
to  have  recourse  to  an  operation,  but  we  yet  find  that  this  greatly 
facilitates  the  continued  use  of  the  eyes  for  near  objects.  On  excluding 
the  affected  eye  from  the  act  of  vision  by  shading  it  with  our  hand, 
we  observe  that  it  then  moves  inwards,  even  although  the  object  is  held 
within  its  range  of  accommodation ;  its  fixation  was,  therefore,  forced. 
On  testing  such  cases  with  prismatic  glasses,  the  internal  rectus  muscle 
is  generally  found  to  be  abnormally  strong.  It  is,  therefore,  necessary 
to  weaken  it,  and  thus  restore  the  equilibrium,  so  that  the  strength  of 
the  different  muscles  of  the  eyeball  may  be  evenly  balanced.  But  great 
care  must  be  taken  that  we  do  not  produce  too  great  an  eflfect,  and 
render  convergence  of  the  optic  axes  for  near  objects  impossible. 
Hence  the  power  of  convergence  for  a  very  near  point  (3"  to  4")  must 
always  be  carefully  and  accurately  tested,  and  if  it  is  found  that  it 
is  only  produced  with  difficulty,  the  eff'ect  of  the  operation  must  be 
at  once  diminished  by  a  conjunctival  suture.  In  order  that  we  may 
not  be  misled  by  the  temporary  insufficiency  of  the  divided  muscle, 
which  afterwards  partly  disappears  again.  Yon  Graefe  recommends  that 
the  point  of  fixation  (both  for  near  and  distant  objects)  should  not 
lie  in  the  median  line,  but  towards  the  temporal  side  of  the  operated 
eye.  For  in  this  position,  the  temporary  insufficiency  of  the  internal 
rectus  will  come  less  into  play,  and  the  temporary  result  will  cor- 
respond more  closely  to  the  permanent. 

In  slight  cases  of  this  form  of  periodic  squint,  it  may  suffice  to  give 
the  patient  concave  glasses,  so  that  he  may  be  able  to  hold  the  object 
(book,  etc.)  at  a  greater  distance.  Or,  again,  we  may  combine  the 
concave  glasses  with  abducting  prisms. 

Operation  for  the  cure  of  Diplopia. — We  are  sometimes  called  upon  to 
operate  for  the  care  of  diplopia,  the  deviation  of  the  optic  axis  being, 
at  the  same  time,  perhaps,  hardly  perceptible.  These  form  the  most 
difficult  and  intricate  cases,  for  here  less  depends  upon  mere  manual 
dexterity  than  upon  a  complete  mastery  of  the  theoretical  portion  of 
the  subject,  and  a  thorough  knowledge  of  the  actions  of  the  muscles 
of  the  eyeball,  and  their  effect  upon  the  position  of  the  vertical  meridian, 
etc.  Having  already  explained  these  subjects,  I  shall  only  mention 
the  chief  points  to  be  considered  in  the  treatment.  We  must,  in 
the  first  place,  ascertain  in  what  directions  prisms  have  to  be  turned 


598       AFFECTIONS  OF  THE  MUSCLES  OP  THE  EYE. 

in  order  to  fuse  tlie  double  images,  and  whether  any  active  tendency 
exists  to  unite  the  images  if  they  are  closely  approximated.  We 
find  that  certain  kinds  of  double  images  are  far  more  difficult  to 
unite  than  others.  It  is  quite  impossible  to  fuse  images  which  are  of 
a  different  height,  except,  indeed,  this  difference  be  of  the  very  slightest, 
equalling  a  prism  of  1°.  Crossed  double  images  again,  are  far  more 
difficult  to  unite  than  homonymous.  If  the  double  images  show  a 
difference  in  height,  we  must  first  endeavour  to  remedy  this  by  an 
operation,  and  then,  when  this  is  cured,  the  patient  may  be  able  to  fuse 
them  if  they  are  sufficiently  close  to  each  other.  Shoiild  they  be 
crossed,  we  must  change  them  into  homonymous,  and  approximate 
them  closely  to  each  other,  so  that  they  may  be  easily  united. 

SeconJary  Strabismus  after  Paralysis  of  the  Opponent  Muscle. — 
Our  treatment  must  vary  with  the  amount  of  immobility  in  the  direc- 
tion of  the  paralysed  muscle.  Let  us  assume  that,  after  a  paralysis  of 
the  abductor,  the  immobility  outwards  amounts  to  from  1  to  1-j  line, 
but  that  there  is  no  deviation  inwards,  so  that  the  diplopia  only  extends 
up  to  the  middle  line,  or  but  slightly  into  the  opposite  half  of  the  field 
of  vision.  In  such  cases,  a  simple  tenotomy  of  the  internal  rectus  will 
generally  suffice.  If  the  immobility  exceeds  1  or  \\  line,  ranging 
between  this  and  2  or  2|^  lines,  a  simj^le  tenotomy  will  not  suffice,  and 
we  must  then  bring  forward  the  insertion  of  the  paralysed  muscle 
(operation  of  "  re-adjustment"),  and  combine  with  this  a  tenotomy  of 
the  opponent  and  a  suture.  If  the  want  of  mobility  in  the  direction 
of  the  paralysed  muscle  exceeds  2^  lines,  we  must  bring  forward  the 
paralysed  muscle,  and,  at  the  same  time,  divide  its  opponent.  Our 
object  in  bringing  forward  the  insertion  of  the  paralysed  muscle  is  to 
afford  it  an  increased  amount  of  power  over  the  eyeball ;  for,  the  more 
anterior  its  insertion,  the  greater  its  power. 

The  operation  of  re-adjustment,  together  with  the  tenotomy  of  the 
opponent  muscle,  may  be  performed  either  according  to  Yon  Graefe's, 
Critchett's,  or  Liebreich's  method. 

Von  Graefe's  mode  of  operating  is  as  follows  : — The  lids  being  kept 
apart  by  the  speculum,  the  insertion  of  the  paralysed  internal  rectus 
is  to  be  divided  just  as  in  the  operation  for  squint,  but  its  connection 
with  the  sclerotic  is  to  be  more  freely  severed,  and  the  connective  tissue 
on  each  side  of  the  muscle  more  largely  incised.  The  conjunctival 
wound,  though  larger  than  in  an  ordinary  tenotomy,  should  not  be  too 
considerable.  We  must  carefully  sever  the  conjunctiva  from  the 
superficial  portion  of  the  muscle.  Although  the  latter  will  still  adhere 
to  the  lateral  expansions  of  the  capsule  of  Tenon,  it  will  be  freely 
moveable  upon  the  sclerotic,  so  that  the  free  end  of  the  tendon  can  be 
brought  up  to,  or  even  beyond,  the  edge  of  the  cornea.  In  order  to 
retain  it  in  this  position,  the  eye  must  be  turned  inwards  as  far  as 


TREATMENT   OF   STRiVBISMUS.  599 

possible,  and  be  immoveably  kept  in  this  position  until  the  tendon  has 
reunited  with  the  sclerotic  at  the  desired  point.  We  need  not  fear  any 
ill-effect  to  the  cornea,  for  its  epithelial  layer  prevents  any  union 
between  it  and  the  tendon.  We  must  next  pass  on  to  the  tenotomy  of 
the  abdactor.  A  large  squint-hook  having  been  passed  beneath  the 
tendon,  we  take  a  silk  thread,  carrying  a  curved  needle  at  each  end, 
and  thrust  one  needle  from  without  inwards  through  the  lower  third 
of  the  tendon,  so  as  to  bring  it  out  below  the  lower  edge ;  the  other 
needle  is  then  to  be  passed  in  the  same  way  through  the  upper  third 
of  the  tendon.  The  free  ends  of  the  thread  are  then  to  be  tied,  so 
that  the  suture,  which  is  situated  betweenthe  insertion  of  the  muscle 
and  the  hook,  will  include  the  two  external  thirds  of  the  tendon. 
The  tendon  is  next  to  be  completely  divided  behind  the  suture,  so  that 
the  latter  is  left  jBrmly  attached  to  the  stump.  The  eye  is  then  to  be 
rolled  inwards  as  far  as  possible,  and  is  to  be  maintained  in  this  position 
by  the  threads,  which  should  be  fastened  firmly  to  the  bridge  of  the 
nose  by  strips  of  plaister.  In  order  to  maintain  perfect  immobility  of 
the  eyes,  I  generally  bandage  up  the  healthy  eye.  Cold  water  dressings 
are  to  be  constantly  applied  so  as  to  subdue  any  inflammatory  symp- 
toms.    The  threads  should  be  left  in  for  from  twenty  to  thirty  hours. 

The  following  is  Mr.  Critchett's  mode  of  operating: — All  the  parts 
covering  the  inner  side  of  the  globe  are  to  be  dissected  oflp  from  the 
sclerotic  (in  cases  in  which  a  former  operation  for  convergent  squint 
has  been  followed  by  secondary  divergent  strabismus),  including  con- 
junctiva, subconjunctival  fascia,  old  cicatrix  and  muscle,  with  the  con- 
densed tissue  around  it.  He  next  divides  the  external  rectus,  and 
finally  passes  sutures  through  the  flap  which  has  been  raised  at  the 
inner  side  of  the  eye,  first  excising  a  portion  of  conjunctiva,  and  stitches 
this  to  the  small  portion  of  conjunctiva  left  standing  at  the  inner 
edge  of  the  cornea.  In  this  way,  the  whole  muscular  layer  of  the 
internal  rectus  is  brought  forward.  I  have  found  this  operation  very 
successful  in  several  instances,  and  prefer  it  to  Von  Graefe's  on  account 
of  the  greater  ease  and  certainty  with  which  the  tendon  of  the  muscle, 
whose  insertion  we  have  brought  forward,  is  kept  in  its  new  situation. 

Secondary  Strabismus  following  tenotomy  of  the  opponent,  should  be 
treated  in  the  same  way  as  that  consequent  upon  paralysis  of  the 
opponent  muscle ;  the  prognosis  is,  however,  more  favourable  than  in 
the  latter  case. 

Dr.  Liebreich  has  favoured  me  with  the  following  communication 
respecting  his  method  of  performing  the  operation  of  re-adjustment. 
He  says,  "  The  same  anatomical  considerations  which  led  me  to  devise 
a  modification  of  the  operation  of  tenotomy,  have  caused  me  to  modify 
the  operation  of  bringing  forward  the  insertion  of  the  muscle.  It 
appeared  to  me  to  be  especially  desirable  to  obviate  the  necessity  of 


600       AFFECTIONS  OF  THE  MUSCLES  OP  THE  EYE. 

excising  a  portion  of  conjunctiva,  from  which  I  have  observed  con- 
siderable disadvantages  accrue.  I,  therefore,  operate  in  the  following 
manner : — After  having  made  a  broad  vertical  incision  in.  the  con- 
junctiva in  the  region  of  the  insertion  of  the  muscle,  or,  still  better, 
slightly  behind  it,  I  carefully  dissect  the  conjunctiva  from  the  sub- 
jacent parts,  not  only  towards  the  periphery,  but  also  close  up  to  the 
cornea.  I  next  divide  the  tendon,  and  prolong  the  incision  in  the 
capsule  of  Tenon  upwards  and  downwards.  The  muscle  and  the  portion 
of  capsule  pertaining  to  it  having  been  thus  rendered  freely  moveable, 
I  next  pass  at  least  two  sutures  (the  thread  carrying  a  needle  at  each 
end)  through  the  conjunctiva,  close  to  the  edge  of  the  cornea,  and 
through  the  conjointly-seized  edge  of  the  tendon  and  capsule  of  Tenon. 
In  tying  these  sutures,  both  the  muscle  and  the  capsule  of  Tenon  are 
brought  up  quite  close  to  the  margin  of  the  cornea,  and  retained  in  this 
position,  remaining,  however,  covered  by  conjunctiva.  The  wound  in 
the  conjunctiva  is  to  be  closed  by  the  common  sutures." 

11.— MUSCULAR  ASTHENOPIA  (mSUFFICIENCT  OF  THE 
mTBRNAL  RECTI  MUSCLES). 

This  afiection  is  of  common  occurrence,  and  is  characterised  by 
very  marked  symptoms  of  asthenopia,  which  sometimes  prove  so 
irksome  and  harassing  to  the  patient  as  to  incapacitate  him  from 
reading,  etc.  Such  patients  complain  that  after  they  have  been 
working  or  reading  for  a  certain  length  of  time,  the  eyes  become  hot 
and  uncomfortable,  the  print  grows  dim,  the  letters  become  confused 
and  run  into,  or  overlap,  each  other.  This  is  generally  preceded  by  a 
feeling  of  tension  and  weight  in  the  eyes  and  over  the  brow,  and 
some  patients  distinctly  feel  how  the  one  eye  becomes  unsteady  and 
wavering  in  its  fixation,  and  then  moves  gradually  outwards.  They 
often  also  anticipate  these  symptoms  by  closing  one  eye.  After  rest- 
ing for  a  short  time,  reading  may  be  resumed,  to  be,  however,  again 
interrupted  by  the  same  train  of  symptoms.  On  examining  the  eyes, 
we  find  that  they  look  normal,  that  the  acuity  of  vision  and  range 
of  accommodation  are  good,  but  that  there  is,  as  a  rule,  a  considerable 
degree  of  myopia.  If  we  direct  the  patient  to  look  steadily  with  both 
eyes  at  an  object  (a  pencil,  or  our  finger),  and  gradually  approximate 
this  to  the  eye,  we  find  that  when  the  object  is  brought  to  about  6" 
from  the  patient,  the  one  eye  becomes  unsteady  and  wavering  in  its 
fixation,  and  then  either  gradually  and  slowly,  or  suddenly  and  spas- 
modically, deviates  outwards.  The  same  deviation  occurs  (even 
perhaps  if  the  object  is  some  feet  distant)  when  we  cover  one  eye 
with  our  hand  or  a  slip  of  ground  glass,  so  as  to  exclude  it  from 
participation    in    binocular  vision.     Such    a  deviation   will   likewise 


JIUSCULAR   ASTHENOPIA.  601 

manifest  itself,  if  a  prism  is  held  with  its  base  upwards  or  downwards 
so  as  to  produce  diplopia,  for  the  double  images  cannot  be  fused  into 
one,  as  the  eyes  are  unable  to  unite  double  images  which  show  any, 
but  the  very  slightest,  difference  in  height.  This  is  a  much  more 
delicate  test  than  that  of  covering  one  eye  with  our  hand,  for  it  will 
enable  us  to  detect  degrees  of  deviation  of  the  optic  axes,  which  are 
too  slight  to  be  appreciated  by  the  eye. 

We  find  that  the  normal  eye  is  generally  able  to  overcome  a  prism 
of  from  20°  to  30°  with  its  base  turned  outwards,  and  one  of  6°  or  8°  with 
its  base  turned  inwards.  This  is  owing  to  the  fact  that  the  internal 
rectus  is  much  stronger  and  more  exercised  than  the  external.  But 
very  few  persons  can  overcome  more  than  a  prism  of  1°  with  its  base 
turned  upwards  or  downwards.  In  consequence  of  this,  diplopia 
will,  therefore,  be  produced,  the  visual  impulse  will  be  annulled,  and 
the  eye  yield  to  the  preponderating  influence  of  the  strongest  muscle. 
In  the  normal  eye  the  muscles  are  equally  balanced,  and  the  double 
images  wiU  only  show  a  difference  in  height,  standing  straight  one 
above  the  other.  But  if  either  the  internal  or  external  rectus  con- 
siderably exceeds  the  normal  standard  of  strength,  the  double  imao-es 
will  not  only  show  a  difference  in  height,  but  also  a  lateral  difference. 
If  the  internal  rectus  is  insufficient,  the  eye  will  move  outwards  when 
a  prism  is  held  with  its  base  upwards  or  downwards,  and  there  will, 
consequently,  be  not  only  a  difference  in  the  height  of  the  double 
images,  but  they  will  also  be  crossed,  on  account  of  the  divergent 
squint.  We  may  then  easily  express  the  degree  of  insufficiency  by  the 
degree  of  the  prism  (base  turned  inwards)  which  is  required  to  bring 
the  double  images  one  above  the  other.  This  mode  of  examination  is 
particularly  recommended  by  Yon  Graefe,  who  employs  the 
following  plan.  A  dot  is  drawn  on  a  piece  of  paper,  and  is  °' 
bisected  by  a  fine  vertical  line  (Fig.  84).  This  paper  is  placed 
at  the  usual  distance  of  reading  or  writing,  and  the  patient  is 
directed  to  regard  the  dot  with  both  eyes.  A  prism  of  14° 
(with  it  base  upwards)  is  then  to  be  placed  in  front  of  one 
eye.  This  will  at  once  produce  diplopia,  and  the  image  of  the 
eye  before  which  the  prism  is  held  will  be  beneath  that  of  the 
other  eye.  If  the  eyes  are  normal,  the  double  images  will 
only  show  a  difference  in  height,  but  not  any  lateral  difference, 
they  will  lie  straight  above  one  another.  But  if  the  internal 
rectus  is  insufficient,  the  eye  moves  outwards,  and  conse- 
quently the  double  images  will  not  only  show  a  difference  in 
height, but  also  a  lateral  difference,  and  they  will  be  crossed.  We 
next  try  what  prism  (with  its  base  inwards)  is  required  to  neu- 
tralize the  effect  of  this  deviation,  and  bring  the  images  straight 
above  each  other.     In  order  to  ascertain  whether  the  images 


002       AFFECTIONS  OP  THE  MUSCLES  OF  THE  EYE. 

are  crossed  or  homonymous,  we  place  a  slip  of  red  glass  before  the  other 
eye,  and  this  will  enable  iis  at  once  to  distinguish  which  image  belongs 
to  the  left,  and  which  to  the  right  eye.  After  the  presence  and  degree 
of  insufficiency  have  been  thus  determined,  we  should  proceed  to  test 
the  relative  strength  of  the  internal  and  external  rectus  of  each  eye,  by 
ascertaining  the  strongest  prism  which  they  are  able  to  overcome.  The 
best  object  to  be  used  for  this  purpose  is  a  lighted  candle,  or  a  roll  of 
paper,  which  is  to  be  held  at  a  distance  of  from  6  to  10  feet.  We  then 
place  prisms  of  various  strength  before  one  eye,  turning  the  base  first  out- 
wards, in  order  to  find  the  strongest  prism  with  which  the  patient  sees 
single,  and  this  gives  us  the  strength  of  the  internal  rectus.  The  external 
rectus  of  the  same  eye  is  next  to  be  tried  ;  and  then  the  other  eye  should 
be  examined  in  the  same  manner.  Insufficiency  of  the  internal  recti  is 
most  frequently  met  with  in  cases  of  considerable  myopia.  The  reason 
of  this  can  be  readily  understood,  if  we  remember  that  a  person  with  a 
myopia  of  ^  would  have  to  hold  any  small  object  (a  book,  etc.)  at  a  dis- 
tance of  about  5".  This,  however,  necessitates  a  considerable  degree  of 
convergence  of  the  visual  hues,  and  great  exertion  of  the  internal  recti 
muscles.  After  a  time  the  latter  become  fatigued,  symptoms  of  asthe- 
nopia arise,  and  if  the  work  is  persisted  in,  one  eye  deviates  outwards. 
But  a  temporary  insufficiency  of  the  internal  recti  may  also  be  produced 
by  severe  constitutional  diseases,  which  greatly  weaken  the  system 
(such  as  fevers,  diphtheria,  etc.),  but  it  disappears  when  the  patient  has 
regained  his  strength.  It  may  also  co-exist  with  hypermetropia,  and 
its  presence  should  always  be  suspected,  if  the  symptoms  of  asthenopia 
persist  in  spite  of  the  use  of  convex  lenses. 

The  disease  may  be  treated  in  various  ways,  according  as  our 
purpose  is  merely  to  alleviate  the  asthenopia,  or  to  cure  it.  It  may 
be  alleviated  by  the  use  of  concave  glasses  for  reading  and  working,  so 
that  the  patient  can  hold  the  object  at  a  distance  of  12"  or  14,"  and 
thus  require  a  much  less  degree  of  convergence.  Moreover,  the  iTse  of 
prisms  with  their  base  turned  inwards  will  relieve  the  internal  recti, 
but  the  fear  is  that,  from  want  of  sufficient  exercise,  those  muscles 
should,  after  a  time,  become  still  weaker.  This  mode  of  using  prisms 
is  only  indicated  in  the  slighter  cases  of  insufficiency,  or  if  there  is  only 
a  very  limited  power  of  abduction  for  distance,  so  that  there  is  a  risk  of 
producing  convergent  squint  by  a  tenotomy  of  the  external  rectus. 
These  prisms  may  often  be  advantageously  combined  with  concave 
glasses. 

Again,  the  internal  recti  may  be  strengthened  by  frequent  exercises 
with  prisms  (whose  base  is  turned  outwards).  The  object  (a  lighted 
candle,  white  wand,  etc.)  is  to  be  placed  at  a  distance  of  6  or  8  feet, 
and  a  prism,  with  its  base  outwards,  should  be  held  before  one  eye. 
Crossed  diplopia  will  be  produced,  and  in  order  to  overcome  this  the 


IVIUSCULAR  ASTHENOPIA.  603 

patient  will  voluntarily  squint  inwards.  The  strength  of  the  prisms 
may  be  gradually  increased,  but  should  not  be  too  strong  at  first,  other- 
wise the  internal  rectus  will  be  weakened  by  over- exertion.  If  the 
patient  is  short-sighted,  he  should  wear  concave  glasses  when  he  is 
looking  at  the  object.  This  plan  of  treatment,  however,  requires 
much  patience  and  accui^acy,  and  generally  soon  proves  ii-ksome  to  the 
patient. 

The  best  mode  of  treatment  consists  in  the  division  of  the  external 
recttis,  for  we  thus  indirectly  strengthen  the  internal  rectus  which  will 
have  a  less  resistance  to  overcome.  In  a  myopia  of  j-,  our  chief 
object  must  be  to  enable  the  patient  to  converge  easily,  and  for  some 
time,  for  a  distance  of  about  4^",  as  he  will  hold  the  print,  or  his  work 
at  about  5k"  or  6". 

Even  if  a  slight  convergent  squint  is  produced  for  distance,  it  is 
of  little  consequence,  as  this  may  be  readily  neutralized  by  an  effort  of 
the  external  rectus.  The  amount  of  convergence  which  may  be  allowed 
for  distance,  must  depend  entirely  upon  the  relative  strength  of  the 
internal  and  external  recti,  and  their  power  should  therefore  be  care- 
fully tested  with  prisms  before  any  operation  is  undertaken.  Thus,  if 
in  a  myopia  of  j-,  the  internal  rectus  could,  before  the  operation,  only 
overcome  a  prism  of  4°  or  5°,  but  the  external  rectus  one  of  14°  or  16°, 
it  would  be  perfectly  safe  to  permit  a  convergence  of  ^"'  or  1'"  for 
distance,  more  particularly  if  the  excluded  eye  had,  before  the  opera- 
tion, deviated  outwards  f "  or  1'"  when  covered.  In  such  a  case,  even 
after  its  division,  the  external  rectus  would  remain  sufficiently  strong  to 
rectify  the  convergent  squint.  The  following  considerations  must 
guide  us  as  to  the  extent  of  the  tenotomy: — 1.  The  degi^ee  of  the 
myopia,  and  the  consequent  distance  for  which  the  optic  axes  must 
converge  in  reading,  etc.  2.  The  strength  of  the  prisms  which  can  be 
overcome  by  the  internal  and  external  recti.  The  strength  of  the 
prism  which  can  be  overcome  for  distance  by  the  external  recti  gives 
us  a  clue  as  to  the  extent  of  the  tenotomy,  for  we  may  correct  with 
safety  the  deviation  outwards  which  corresponds  to  the  strength  of  these 
prisms.  Von  Graefe  has  found  that  the  primary  effect  of  the  operation 
may  even  exceed  this  by  f"  or  f ",  so  that,  at  a  distance,  homonymous 
double  images  arise  in  the  middle  Kne,  which  require  a  prism  of  1 0°  to 
unite  them.  As  long  as  this  is  not  exceeded,  we  need  not  fear  that 
the  homonjTnous  diplopia  will  remain  permanently.  In  order  not  to 
be  misled  by  the  temporary  insufficiency  of  the  external  rectus,  it  is 
better  not  to  hold  the  object  in  the  median  line,  but  15°  or  20°  to 
the  nasal  side  of  the  operated  eye  (Graefe).  3.  The  degree  of  devia- 
tion outwards  (in  looking  at  distant  objects),  which  occurs  when 
the  affected  eye  is  covered.  The  less  this  divergence  is,  the  more 
careful  must  we  be  with  the  tenotomy.     If  the  degree  of  insufficiency 


604       AFFECTIONS  OF  THE  MUSCLES  OF  THE  EYE. 

exceeds  tile  prism  whicli  the  eye  can  overcome  at  a  distance  by  abduc- 
tion, we  m.ust  only  partially  correct  tlie  insufficiency,  and  limit  the 
effect  of  the  operation  by  a  conjunctival  suture.  We  may  also  assist 
the  effect  of  the  operation  by  using  prismatic  glasses  with  the  base 
inwards,  for  reading,  etc.  Where  the  power  of  abduction  is  extremely 
slight,  and  the  insufficiency  at  a  distance  almost  nil,  tenotomy  is 
conti^a-indicated,  for  it  would  be  sure  to  be  followed  by  a  convergent 
squint  and  consequent  diplopia  for  distance.  In  such  cases,  the  asthen- 
opia naust  be  alleviated  by  prismatic  glasses.  4.  The  mode  of  de- 
viation when  the  object  is  approximated  to  the  eye.  This  test  is, 
however,  less  accurate  than  the  preceding  ones.  Von  Graefe  thinks 
that  a  considerable  correction  is  indicated,  if  the  eye  moves  suddenly 
and  spasmodically  outwards  at  the  moment  when  the  insufficiency  of 
the  internal  recti  shows  itself;  whereas,  we  must  be  more  guarded  in 
the  extent  of  the  operation,  if,  as  the  object  is  brought  gradually  nearer 
to  the  eyes,  the  one  moves  outwards  in  about  the  same  ratio  as  the 
other  moves  inwards,  making  an  associated  movement  with  this.  Still 
more  cautious  must  we  be,  if  the  affected  eye  remains  stationary  at  a 
certain  point,  without  apparently  deviating  any  further  outwards. 

If  both  external  recti  are  much  weaker  than  normal,  and  if  the  devia- 
tion under  the  covered  hand  exceeds  1^'"  or  2'",  a  double  operation 
will  be  necessary.  This,  however,  should  never  be  done  at  one  sitting. 
We  should  first  divide  the  external  rectus  of  the  eye  most  affected,  and 
then,  after  a  few  days,  when  the  final  result  of  the  operation  is  appa- 
rent, the  other  eye  must  be  carefully  and  accurately  examined,  in  order 
to  ascertain  to  what  degree  the  insufficiency  still  remains,  and  to  what 
extent  the  operation  is  indicated.  It  is  always  safest  at  the  second 
operation  to  divide  the  abductor  very  carefully  and  very  close  to  its 
insertion,  and  then  to  test  the  accommodative  movements  of  the  eyes, 
the  amount  of  convergence  at  a  distance,  and  the  prism  required  to 
overcome  the  homonymous  diplopia,  and  if  the  convergence  at  all 
exceeds  our  wishes,  to  insert  a  conjunctival  suture. 


Chapter  XV. 
DISEASES  OF  THE  LACHRYMAL  APPARATUS. 


1.— DISEASES  OF  THE  LACHRYMAL  GLAN'D. 

LiflammaHon  of  the  lachrymal  gland  (D aery o- adenitis)  is  generally 
chronic  in  character,  and  gives  rise  to  a  more  or  less  considerable,  firm, 
nodulated,  immoveable  swelling  at  the  tipper  and  outer  margin  of  the 
orbit.  The  upper  portion  of  the  tumour  disappears  beneath  the  edge  of 
the  orbit,  but  can  be  readily  followed  if  the  tip  of  the  little  finger  is 
inserted  beneath  the  upper  and  outer  orbital  ridge.  The  skin  is  move- 
able over  the  tumour,  and  the  upper  eyelid  is  somewhat  reddened  and 
puffy,  sometimes,  indeed,  the  redness  and  swelling  may  be  very  con- 
siderable, so  that  the  upper  eyelid  hangs  down  in  a  thick,  massive  fold 
over  the  lower.  The  conjunctiva  is  somewhat  injected  and  swollen, 
especially  at  the  retro-tarsal  fold,  and  there  may  also  be  considerable 
chemosis.  As  a  rule,  the  swelling  is  but  slightly  painful,  either  spon- 
taneously, or  to  the  touch ;  but  if  the  inflammation  is  very  acute,  the 
pain  may  be  severe,  and  extend  to  the  corresponding  side  of  the  face 
and  head.  If  the  swelling  acquires  any  considerable  size,  the  eyeball 
will  be  displaced  downwards  and  inwards,  and  its  movements  be 
impaired  in  the  opposite  direction.  The  inflammation  generally  runs 
a  very  chronic  and  protracted  course,  the  swelling  either  gradually 
undergoing  absorption,  or  chronic  suppuration  occurring.  But  if  the 
tumour  is  so  large  as  to  displace  the  eyeball,  or  to  impair  its  mobility, 
it  wiU  be  necessary  to  remove  it.  Sometimes  both  lachrymal  glands* 
become  simultaneously  inflamed,  giving  rise  to  a  symmetrical  swelHng  at 
the  upper  and  outer  edge  of  each  orbit.  In  rarer  instances,  the  inflam- 
mation assumes  an  a(jute  and  sthenic  character,  there  being  great  heat, 
redness,  and  swelling  of  the  part,  with  perhaps  a  rapid  formation  of 
pus,  so  that  the  disease  assumes  all  the  appearances  of  an  acute  abscess. 
The  latter  points,  the  skin  gives  way,  and  there  is  an  escape  of  pus,  which 
may  continue  to  ooze  out  for  some  length  of  time ;  subsequently  the 

*  Vide  Hayncs  Walton,  "  Med.  Times  and  Grazette,"  1854,  p.  317 ;  and  Horner, 
"  Kl.  Monatsbl.,"  1866,  p.  257. 


606  DISEASES   OF   THE   LACHRYMAL   APPARATUS. 

opening  closes,  tlie  inflammatory  products  become  absorbed,  and  tbe 
swelling  gradually  disappears.  Sometimes,  however,  the  aperture 
remains  patent,  and  a  minute  fistulous  opening  is  established,  through 
which  the  tears  ooze  forth.  The  fistula  may  also  occur  in  chronic  sup- 
puration of  the  gland,  being  situated  either  on  the  external  skin  or  on 
the  conjunctival  surface.  Such  fistulas  prove  extremely  obstinate  and 
intractable  in  the  treatment,  and  if  the  aperture  should  become  acci- 
dentally stopped  up,  severe  inflammatory  symptoms  may  supervene. 
Inflammation  of  the  lachrymal  gland  may  be  due  to  cold,  or  to  a  trau- 
matic origin.  It  may  also  supervene  upon  chronic  inflammation  of  the 
conjunctiva  or  cornea.  Von  Grraefe  mentions  cases  in  which  chronic 
swelling  and  congestion  of  the  gland  were  produced  by  the  protracted 
use  of  a  compress  bandage,  the  retention  of  the  tears  in  the  gland 
probably  exciting  irritation. 

In  chronic  dacryo-adenitis  we  may  endeavour  to  produce  absorption 
of  the  inflammatory  products  by  the  local  application  of  ointments  con- 
taining iodide  of  potassium,  iodine,  or  mercury;  or  by  painting  tincture 
of  iodine  over  the  part.  In  the  acute  form,  hot  cataplasms  and  leeches 
should  be  applied,  and  'if  suppuration  threatens,  a  free  incision  should 
be  made  into  the  swelling.  The  same  is  to  be  done  if  pus  is  formed  in 
chronic  cases. 

Sim/pie  hypertrophy  of  the  lachrymal  gland  is  a  rare  affection,  and 
may  occasionally  be  somewhat  difiicult  to  diagnose  with  certainty.  It 
may  ensue  upon  repeated  inflammatory  attacks,  or  occur  spontaneously, 
and  is  most  frequently  met  with  in  children  ;  indeed  it  may  even  be 
cono-enital.  This  condition  is  particularly  characterised  by  the  extreme 
slowness  with  which  the  swelling  increases  in  size,  and  the  absence  of 
all  redness,  pain,  or  other  inflammatory  symptoms.  The  tumour  is 
circumscribed,  more  or  less  firm,  elastic,  and  nodulated,  and  may  in 
time  acquire  so  considerable  a  size,  as  to  displace  the  eyeball  and  curtail 
its  movements.  Attempts  should  be  made  to  disperse  it  by  the  appli- 
cation of  iodine,  mercurial  ointment,  etc. ;  but  these  remedies  generally 
prove  unavailing  and  recourse  must  be  had  to  operative  interference. 

Cysts  of  the  lachrymal  gland*  (Dacryops)  are  of  very  rare  occur- 
rence, and  present  the  appearance  of  a  little  tumour,  varying  in  size 
from  a  small  bean  to  a  hazel  nut,  in  the  upper  and  outer  portion  of 
the  upper  eyelid,  and  extending  back  beneath  the  edge  of  the  orbit.  If 
at  all  considerable  in  size,  it  is  at  once  observable  to  the  eye,  and  readily 
so  to  the  touch.  On  everting  the  lid,  there  is  noticed,  close  beneath  the 
conjunctiva,  a  bluish-pink,   semi-transparent,   elastic,    and  somewhat 

*  Vide  a  very  interesting  paper  on  this  subject  by  Mr.  Hulke,  "  R.  L.  O.  H. 
Eep.,"  1,  285. 


DISEASES   OF   THE   LACHRYMAL   GLAND.  G07 

fluctuating  swelling,  consisting,  perhaps,  of  several  nodulated  segments 
of  varying  size.  It  springs  still  more  into  view,  if  the  lid  is  retracted 
and  pressed  in  a  downward  direction.  The  swelling,  moreover,  increases 
suddenly  and  markedly  in  size  if  the  patient  cries,  or  the  secretion  of 
tears  is  stimulated  by  the  application  of  some  irritant  to  the  conjunctiva. 
The  cyst  is  generally  due  to  the  stoppage  of  one  or  more  of  the  excre- 
tory ducts  of  the  gland,  so  that  the  tears  are  retained,  and  distend  the 
portion  of  the  duct  and  gland  above  the  point  at  which  the  obstruction 
is  situated.  The  duct  is  sometimes,  however,  patent,  so  that  the  tears 
may  slowly  ooze  out,  and  the  cyst  be  emptied  by  pressure.*  Accord- 
ing to  Schmidt,t  the  disease  is  sometimes  congenital.  The  best  mode 
of  treatment  is  to  establish  an  artificial  opening  on  the  inside  of  the 
conjunctiva,  so  that  a  free  exit  may  be  afforded  for  the  escape  of  the 
tears.  For  if  an  attempt  is  made  to  remove  the  cyst  entire,  we  shall 
generally  fail,  as  its  wall  is  very  delicate,  and  the  tumour  is  very  apt  to 
recur.  Moreover,  there  is  much  fear  of  leaving  a  small,  fistulous 
opening,  which  may  prove  extremely  obstinate  and  intractable  in  the 
treatment.  "Wecker  has,  however,  lately  recorded  a  successful  case  of 
removal  of  a  dacryops.|  An  artificial  opening  of  sufficient  size  may  be 
gained  by  simply  making  a  linear  incision  of  from  1^'"  to  2'"  in  extent, 
and  keepiiig  it  patent  by  passing  a  probe  every  day  along  its  edges, 
until  the  latter  have  become  cicatrized.  Or  again.  Von  Graefe's§  plan 
may  be  adopted,  of  passing  a  fine,  threaded,  cuawed  needle  through  the 
aperture  of  the  duct  (if  this  is  patent)  and  carrying  it  along  the  ante- 
rior wall  of  the  cyst  to  a  distance  of  about  2'",  at  which  point  it  is  to 
be  again  brought  out,  so  that  a  bridge  of  the  anterior  cyst  wall  of 
about  2'"  in  extent  is  included  within  the  thread,  which  is  to  be  tied  in 
a  loose  loop.  The  intermediate  bridge  may  either  be  allowed  to  slough 
through,  or  may  be  divided  at  the  end  of  a  few  days,  and  thus  an  arti- 
ficial opening  will  be  established,  through  which  the  lachi'ymal  secretion 
can  flow  ofi". 

Fistula  of  the  lachrymal  gland  is  occasionally  observed,  and  may 
ensue  upon  dacryops,  or  an  acute  or  chronic  abscess,  or  be  due  to  a 
traumatic  origin,  supervening  upon  some  injury  of  the  gland,  or  some 
operation,  as  for  instance  the  opening  or  removal  of  a  cyst.  The 
fistulous  opening  is  generally  extremely  minute,  only  admitting'  per- 
haps the  point  of  a  very  fine  bristle.  Through  this  little  aperture  the 
tears  ooze  slowly  forth,  and  their  quantity  inci'eases  with  the  augmen- 
tation of  the  secretion  of  the  lachrymal  gland  during  any  mental 
excitement,  or  irritation  of  the  eye  from  dust  or  wind,  astringent  appli- 
cations, etc.     The  affection  often  proves  somewhat  obstinate  and  intract- 

*  Vide  Yon  Graefe,  "A.  f.  O.,"  vii,  2,  1. 

t  Lehre  von  den  Augenkrankheiteu,  1817- 

X  "  Kl.  Monatsbl.,"  1867,  p.  34.  §  "  A.  f.  O.,"  vii,  2,  2. 


608  DISEASES   OF   THE   LACHRYMAL  APPARATUS. 

able.  The  edges  of  the  fistulous  opening  may  be  touched  with  a  fine 
point  of  nitrate  of  silver,  after  the  edges  have  perhaps  been  first  pared ; 
or  the  obliteration  may  be  attempted  by  the  galvano-caustic  apparatus. 
Again,  we  may  succeed  in  occluding  it  by  freshening  the  edges  of  the 
aperture,  and  then  closing  it  with  a  fine  suture.  Sometimes,  however, 
severe  inflammatory  symptoms,  followed  by  the  formation  of  pus, 
ensue  upon  the  heahng  or  blocking  up  of  the  fistulous  opening, 
recurring  again  and  again  with  great  severity.  Alfred  Graefe*  nar- 
rates a  case  of  this  kind,  in  which  he  was  finally  obliged  to  excise 
the  lachrymal  gland,  in  order  to  cure  the  disease  and  relieve  the  patient 
of  this  constant  suffering  and  annoyance.  Mr.  Bowmanf  succeeded  in 
curing  an  obstinate  and  long  established  external  fistula  of  the  lachrymal 
gland,  by  establishing  an  artificial  opening  on  the  conjunctival  surface 
by  a  small  seton,  and  then  closing  the  external  aperture. 

Various  kinds  of  tumour  are  met  with  in  the  lachrymal  gland,  but 
by  far  the  most  frequent  are  those  of  a  sarcomatous  nature.  Whereas, 
cancer  is  of  very  rare  occurrence,  and  is  probably  always  secondary,  ex- 
tending from  the  neighbouring  tissues  to  the  gland.  Knapp  J,  however, 
reports  a  case  of  hypertrophy  of  the  lachrymal  gland  with  carcinoma. 

Sometimes  the  secretions  of  the  gland  may  undergo  chalky  de- 
generation and  dacryoliths  be  formed. 

Extirpation  of  the  lachrymal  gland  may  have  to  be  performed  for 
hypertrophy  or  chronic  inflammation  of  this  organ,  if  it  produces  much 
disfigui'ement  or  displacement  of  the  eyeball.  It  has,  however,  been 
lately  strongly  recommended  as  a  cure  for  very  obstinate  and  severe 
cases  of  lachrymal  disease.  This  operation  has  been  particularly 
practised  by  Mr.  Zachariah  Laurence  for  the  latter  class  of  diseases, 
and  a  full  description  of  the  mode  of  operating  will  be  found  in  his 
paper  upon  the  subject. §  The  patient  having  been. placed  under  the 
influence  of  chloroform,  the  surgeon  is  to  divide  with  a  scalpel  the 
skin,  muscle,  and  fascia  over  the  upper  and  outer  third  of  the  orbit,  to  the 
extent  of  about  an  inch,  so  as  freely  to  enter  the  orbit  at  the  situation 
of  the  lachrymal  gland.  The  latter  may  easily  be  felt  with  the  tip  of 
the  httle  finger,  as  a  small,  hard  body.  If  there  is  any  difficulty  in 
finding  the  gland,  Mr.  Laurence  recommends  that  the  external  com- 
missure of  the  hds  should  be  at  once  divided  by  a  horizontal  incision, 
which  should  meet  the  outer  extremity  of  the  first.  Thus  a  triangular 
flap  will  be  formed  with  its  apex  outwards,  and  the  gland  can  be  more 
readily  reached.  The  latter  is  then  to  be  firmly  seized  with  a  sharp 
hook,  drawn  forth,  and  carefully  excised.  Tolerably  free  hremorrhage 
generally  ensues,  but  this  can  be  readily  arrested  by  the  apphcation  of 
a  stream  of  cold  water.     The  wound  is  to  be  closed  with  fine  silver 

*  "  A.  f.  O.,"  viii,  1,  279.  f  "  R.  L,  O.  H.  Rep.,"  1,  288. 

X  "  Kl.  Monatsbl.,"  1865,  378.  §  "  Oplitbalmic  Review,"  No.  12,  361. 


STILLICIDIUM  LACRYMARUM.  609 

wire  sutures,  this  should  not,  however,  be  done  until  all  bleeding  has 
ceased,  otherwise,  there  may  be  extensive  extravasation  of  blood  into 
the  cellular  tissue  of  the  upper  lid. 


2.— STILLICIDIUM  LACRYMARUM  (EPIPHORA). 

Although  the  term  epiphora  is  generally  applied  to  every  kind  of 
"watery  eye,"  this  is,  strictly  speaking,  erroneous,  and  hence  it  should 
only  be  used  in  those  cases  in  which  there  is  an  undue  secretion  of 
tears,  and  of  the  mucus  secreted  by  the  conjunctiva ;  so  that  the 
canalicuH  cannot  carry  the  tears  off,  but  they  flow  over  the  lids  and 
cheek.  The  epiphora  may  be  due  to  some  irritation  conveyed  to  the 
lachrymal  nerves  from  the  conjunctiva  or  cornea.  Thus,  if  a  foreign 
body  is  lodged  on  the  conjunctiva  or  cornea,  a  considerable  degree  of 
lachrymation  at  once  takes  place.  The  same  occurs  in  many  of  the 
inflammations  of  the  eye,  more  especially  phlyctenular  ophthalmia,  the 
different  forms  of  corneitis,  and  also  in  some  of  the  morbid  changes 
of  the  deeper  tissues  of  the  eyeball.  Mental  emotion  will  also  pro- 
duce it.  The  degree  of  lachrymation  will  of  course  vary  with  the 
nature  and  intensity  of  the  morbid  process,  and  also  according  to  indi- 
vidual cii^cumstances.  From  this  condition  we  must  distinguish  that 
in.  which  there  is  no  hypersecretion  of  tears,  but  the  lachrymation  is 
due  to  an  impediment  or  obstruction  to  their  efilux  through  the  lachry- 
mal passages.  This  is  termed  "  stilUcidhim  lacrijmarum.^^  In  such 
cases  the  tears  collect  at  the  corner  of  the  eye,  causing  the  patient 
frequently  to  wipe  his  eyes ;  or  else  they  slowly  flow  drop  by  drop  over 
the  edge  of  the  lower  lid,  which  gradually  becomes  sore,  red  and 
swollen,  from  the  constant  moistening.  This  irritable  condition  of  the 
lids  then  tends  still  more  to  increase  the  lachrymation,  and  to  alter 
the  position  and  the  structure  of  the  puncta  and  canaliculi.  The  eyes 
often  become  very  irritable,  the  patients  complaining  much  of  the 
constant  pricking,  heat,  and  itching  in  them,  which  is  much  aggra- 
vated by  reading,  writing,  etc.,  and  by  any  exposure  to  bright  light, 
wind,  or  dust.  If  the  true  nature  of  this  irritability  of  the  eye  and  of 
the  lachrymation  is  overlooked,  very  obstinate  and  intractable  inflam- 
mation of  the  edge  of  the  lid  and  of  the  conjunctiva  may  ensue,  which 
sets  defiance  to  every  form  of  coUyrium  or  topical  application,  but 
readily  yields  if  the  impediment  in  the  lachrymal  apparatus  is  removed, 
and  the  stillicidium  cured.  The  obstruction  to  the  efflux  of  the  tears 
may  be  situated  at  any  point  of  the  laclirymal  canal,  at  the  puncta,  the 
canaliculi,  the  sac,  or  the  nasal  duct. 

We  sometimes  notice  in  elderly  persons,   or  after  a  severe  illness, 
that  the  orbicularis  palpebrarum  is  so  much  relaxed,  that  the  tears  are 

2   R 


610  DISEASES   OF  THE  LACHRYMAL   APPARATUS. 

no  longer  propelled  by  it  into  the  puncta,  but  that  they  coUect  in  the 
central  portion  of  the  lower  lid,  which  is  sunk  down  and  somewhat 
everted,  in  the  form  of  a  little  pouch  or  hollow.  In  such  cases,  the 
fluid  does  not  readily  pass  into  the  puncta,  even  although  these  may  be 
patent.  This  relaxation  of  the  orbicularis  is,  in  elderly  persons,  often  due 
to  atrophy  of  the  orbital  cellular  tissiie,  and  perhaps  of  the  orbicularis. 

The  puncta  lacrymalia  may  undergo  certain  changes  of  position 
and  form,  or  even  become  obliterated.  In  their  normal  position,  they 
are  turned  directly  inwards  towards  the  eyeball,  so  that  the  tears  which 
collect  in  the  lacus  lacrymarum  near  the  caruncle  may  be  readily 
guided  into  the  puncta  and  canaliculi,  thence  to  make  theii-  way  through 
the  lachrymal  sac  and  nasal  duct.  Now  when  the  position  of  the 
punctum  is  changed,  so  that  instead  of  being  just  suflEiciently  inverted, 
it  stands  erect  or  is  everted,  the  tears  can  no  longer  enter  it,  but 
must  collect  in  the  corner  of  the  eye  and  overflow  the  lid,  and  a  very 
slight,  perhaps  almost  imperceptible  displacement  will  sufiice  for  this. 
It  has  already  been  stated  that  this  constant  moistening  of  the  lids 
soon  makes  them  very  iin'itablo,  swollen,  and  inflamed,  which  will  tend 
still  more  to  evert  the  punctum.  This  malposition  of  the  puncta  is 
most  frequently  met  with  after  diseases  which  cause  a  shrinking  of  the 
external  skin  of  the  eyelid,  as  for  instance,  eczema,  or  inflammation 
of  the  edge  of  the  lid,  ectropium,  etc.  Also,  if  the  conjunctiva  or 
caruncle  are  much  swollen  or  hypertrophied,  so  that  the  edge  of  the 
lid  is  somewhat  pushed  away  from  the  eye.  Small  tumours  or  cysts, 
situated  close  to  the  puncta  may  also  produce  it.  On  the  other  hand, 
the  malposition  of  the  punctum  may  not  consist  in  its  being  everted, 
but  in  the  edge  of  the  lid  and  punctum  being  turned  in,  which  may 
occur  when  the  eye  is  much  sunken  in  the  orbit.  This  faulty  position 
of  the  punctum  is  very  frequently  overlooked.  The  punctum,  and  a 
portion  of  the  canaliculus,  may  also  be  dilated  and  have  lost  its  con- 
tractility, appearing  in  the  form  of  a  prominent  nipple,  so  that  the 
entrance  of  the  tears  is  rendered  difficult.  Or  again,  the  punctum 
may  be  greatly  contracted  in  size,  or  even  quite  obliterated,  having 
become  covered  by  a  layer  of  epithelium.  This  is  apt  to  be  the  case  in' 
very  chronic  inflammation  of  the  conjunctiva  and  edge  of  the  eyelid, 
in  which  the  secretions  are  altered  and  diminished,  and  a  thin  layer  of 
desiccated  epithelium  is  formed  over  the  free  edge  of  the  lid  and  the 
punctum. 

The  best  mode  of  treating  malposition  of  the  punctum — whether 
it  be  erect,  everted,  or  turned  in — is  by  Mr.  Bowman's  operation  of 
slitting  up  the  punctum  and  the  canaliculus,  and  thus  changing  the 
closed  into  an  open  channel,  into  which  the  tears  can  gain  ready 
entrance.  This  little  operation  may  be  performed  in  various  ways,  and 
although  it  appears  simple  and  easy  enough,  yet  it  sometimes  requires 


STILLICIDITOI   LACRYMARUM.  611 

a  certain  degree  of  nicety  and  care  to  perform  it  quickly  and  with 
success,  more  especially  if  the  patient  is  timid  and  restless.     Let  us 
suppose  that  the  lower  punctum  of  the  right  eye  is  to  be  divided.     The 
patient  should  be  seated  with  his  head  supported  against  the  back  of  an 
arm-chair,  or  the  chest  of  the  surgeon.     The  latter  should  then,  stand- 
ing behind  the  patient,  introduce  a  very  fine  shai'p-pointed  grooved 
director   (Fig.  85)  vertically  into  the  punctum,  and  then,   turning  it 
horizontally,  he  should  run  it  (with  the  groove  upwards)  along 
the  canaliculus  as  far  as  the  inner  edge  of  the  lachrymal  sac.    -^^S-  °  • 
Whilst  the  director  is  passing  along  the  canaliculus,  the  skin        I 
of  the  lower  eyelid  should  be  put  tightly  on  the  stretch,  by 
being  drawn  outwards  and  somewhat  downwards  with   the 
forefinger  of  the  left  hand.    Otherwise,  if  the  lining  membrane 
of  the  canaliculus  is  swollen  or  lax,  it  may  become  tucked  up 
in  front  of  the  director,  and  thus  somewhat  impede  its  pro- 
gress.    When  the  point  of  the  director  has  reached  the  fur- 
ther end  of  the  canaliculus,  it  is  to  be  taken  in  the  left  hand, 
between  the  forefinger  and  thumb,  the  lower  lid  being  at  the 
same  time  put  upon  the  stretch  by  the  ring  finger  of  the 
same  hand.    The  patient  being  then  directed  to  look  upwards, 
the  point  of  a  cataract  knife  (held  between  the  forefinger  and 
thumb  of  the  right  hand,   the  ring-finger  of  which  is  at  the 
same  time  to  raise  the  upper  lid)  is  inserted  into  the  punctura 
and  its  edge  run  along  the  groove  of  the  director  to  the  inner 
wall  of  the  sac,  so  that  the  lower  canaliculus  may  be  slit  up 
to  its  whole  extent.     If  the  patient  is  very  timid  and  restless, 
and  nips  his  eyelids  very  firmly  together,  the  aid  of  an  assistant 
is  generally  required.     To  obviate  this,  some  surgeons  employ 
a  very  fine  pair  of  straight,  blunt-pointed  scissors,  the  one  blade 
of  which  is  to  be  inserted  into  the  punctum  and  run  along  to 
the  extremity  of  the  canaliculus,  which  should  be  at  the  same 
time  put  upon  the  stretch,  and  then  divided  at  one  sharp  cut. 
I  myself  prefer  Bowman's  narrow  probe-pointed  canaliculus 
knife  to  any  other  instrument.     It  should,  however,  be  made 
very  narrow,  and  its  probe-point  be  very  small,  otherwise  it  may 
be  difl&cult  to  enter  it  if  the  punctum  is  very  minute.     In  such  a  case, 
the  latter  should  first  be  somewhat  dilated  with  the  point  of  the  direc- 
tor, and  this  will  generally  sufiice  for  the  ready  admission  of  the  point 
of  the  knife,  which  should  then  be  run,  with  its  sharp  edge  upwards, 
along  the    canaliciilus  quite  up  to  its  extremity,  and  the   latter  be 
.  divided  along  its  whole  course  by  lifting  the  knife  somewhat  from  heel 
to  point.     Care  should  be  taken  that  the  canaliculus  is  divided  to  its 
full   extent.      For  slitting  the    upper  punctum  and    canaliculus  this 
knife,  or  the  grooved  director  and  cataract  knife,  may  also  be  em- 

2  E  2 


612  DISEASES  OF  THE  LACHRYMAL  APPARATUS. 

ployed,  although  I  generally  prefer  Weber's  beak-pointed  knife  for  this 
purpose. 

In  selecting  this  instrument,  we  must  be  particular  that  the  nodular 
point  as  well  as  the  catting  portion  of  the  blade,  are  not  made  too 
large,  else  a  difficulty  will  be  experienced  in  inserting  it  into  the  upper 
punctum,  and  passing  it  along  the  canaliculus.  The  beak  point  should 
be  passed  well  down  into  the  sac,  so  that  the  upper  canaliculus  may  be 
divided  to  its  whole  extent.  The  bleeding  which  follows  the  slitting 
up  of  the  canaliculus  is  generally  but  very  slight,  and  when  it  has 
ceased,  the  film  of  blood-coagulum  should  be  removed  with  a  small 
pair  of  forceps,  from  the  whole  length  of  the  wound,  and  a  little  olive- 
oil  be  applied  to  the  latter,  so  as  to  prevent  its  closing.  Moreover,  it 
is  advisable  to  pass  a  director  along  the  incision  every  day  for  a  few 
days,  so  as  to  keep  this  patent. 

But  the  canalicuh  may  also  be  contracted,  or  partially  or  wholly 
obliterated,  theii*  passage  being  narrowed  by  a  swollen  and  inflamed 
condition  of  the  lining  membrane,  or  from  cicatricial  changes  which  the 
latter  has  undergone,  in  consequence,  perhaps,  of  preceding  inflam- 
mation. Such  cicatrices  are  most  frequently  met  with  after  a  granular 
condition  of  the  lining  membrane,  for  the  granular  inflammation  may 
extend  from  the  conjunctiva  into  the  canal,  and  even  into  the  lachrymal 
sac.  The  cicatrices  may,  however,  be  of  traumatic  origin,  having 
been  perhaps  produced  by  wounds  or  burns,  or  by  the  bruising  and 
tearing  of  the  canal  caused  by  a  clumsy  and  rude  passage  of  the  probes. 
The  swollen  and  turgid  condition  of  the  canaliculus  is  due  either  to 
an  inflammation  extending  to  it  from  the  conjunctiva  or  the  lachrymal 
sac,  or  may  be  caused  by  the  presence  of  some  foreign  body  within  it, 
such  as  an  eyelash,  a  dacryolith,  or  a  small  fungus.  Although  the 
stricture  may  exist  at  any  point  of  the  canaliculi,  it  is  most  frequently 
situated  at  the  spot  where  the  latter  open  into  the  sac. 

If  the  lower  punctum  should  be  obliterated  (atresia)  and  quite 
invisible  on  the  most  careful  search  (aided  by  a  magnifying  lens),  an 
ingenious  operation  of  Mr.  Streatfeild*  may  be  executed,  viz.,  after 
having  divided  the  upper  punctum  and  canaliculus,  a  fine  director 
(suitably  bent)  is  to  be  passed  by  this  aperture  into  the  inferior  cana- 
liculus, and,  if  possible,  through  the  lower  punctum ;  if  not,  the  lower 
canaliculus  can  easily  be  laid  open  upon  it.  This  operation  will  also  be 
found  very  serviceable  in  those  cases,  in  which  the  lower  punctum  and  a 
portion  of  the  lower  canal  are  obhterated.  The  converse  may  also  be  done, 
the  director  may  be  introduced  by  the  lower  punctum,  and  brought  out 
by  the  upper.  These  operations,  however,  often  require  considerable 
dexterity  and  patience. 

If  the  canaliculus  is  only  narrowed,  it  should  be  well  laid  open  in 
*  "  E.  L.  O.  H.  Rep.,"  ii,  4. 


INFLAMMATION   OF   THE  LACHRYMAL   SAC.  613 

the  manner  above  directed.  If  the  stricture  exists  at  the  neck  of  the 
sac,  and  is  firm  and  contracted,  it  should  be  freely  divided  with  a  camila 
knife,  which  is  to  be  introduced  sheathed,  and  then,  when  it  has  arrived 
opposite  the  point  of  stricture,  the  sheath  is  drawn  back,  and  the  blade 
Tincovered.  This  instrument  is  best  introduced  by  the  upper  canaliculus, 
which  should  have  been  previously  divided ;  or  the  stricture  may  be 
incised  wath  Weber's  knife.  After  the  division,  the  stricture  must  be 
treated  by  the  use  of  probes.  I  shall  retui-n  to  this  subject  and  to  these 
instruments  in  treating  of  stricture  of  the  lachrymal  passages.  If  the 
lower  canaliculus  (owing  to  a  swollen  and  thickened  condition  of  the 
lid)  remains  everted,  even  after  having  been  divided,  Mr.  Critchett* 
advises  that  a  portion  of  the  posterior  wall  of  the  canal  should  be  seized 
ajid  snipped  out  with  scissors,  "  thus  effecting  the  treble  objects  of 
drawing  the  canal  more  inwards  towards  the  caruncle,  of  forming  a 
reservoir  into  which  the  tears  may  run,  and  of  preventing  any  reunion 
of  the  parts."  But  if  the  whole  or  the  greater  portion  of  the  lower 
canaliculus  is  obliterated,  it  will  be  different.  In  such  cases,  if  the 
patient  is  troubled  with  epiphora,  theupper  canaliculus  should  be  freely 
slit  open  along  its  whole  extent,  so  that  the  tears  may  gain  an  easy 
entrance.  But  if  this  should  not  suffice,  and  the  lower  canal  be  only 
partially  obliterated,  we  should  endeavour  to  pass  back  a  very  fine 
grooved  director  from  the  opening  in  the  upper  canaliculus  into  the 
lower  one,  and  lay  this  open  upon  the  du-ector. 


3.— IN^FLAMMATION"  OF  THE  LACHRYMAL  SAC 
(DACRYOCYSTITIS). 

This  disease  is  frequently  very  acute  in  character,  and  is  then 
accompanied  by  intense  pain,  which  extends  to  the  corresponding 
side  of  the  head  and  face,  and  there  is,  moreover,  often  marked  con- 
stitutional disturbance  or  feverishness.  The  skin  over  the  region  of 
the  lachrymal  sac  and  its  viciaity  becomes  swollen,  red,  and  glistening, 
and  an  oval  swelling  of  varying  size  appears  at  this  spot.  The  inflam- 
matory swelling  often  also  extends  to  the  eyelids  and  face.  The  former 
become  very  puffy  and  cedematous,  so  that  they  are  only  opened  with 
difficulty,  and  then  it  is  perhaps  noticed  that  the  conjunctiva  is  injected 
and  swollen,  and  that  there  is  a  certain  degree  of  chemosis.  From  this 
great  swelling  of  the  lids  and  face,  the  case  assumes  somewhat  the 
appearance  of  erysipelas  of  the  face,  for  which  it  might  indeed  be  mis- 
taken by  a  superficial  observer.  The  swelling  is  often  very  sensitive, 
the  patient  involuntai'ily  shrinking  back  from  any  attempt  to  touch  it. 

*  Lectures  on  tlie  Diseases  of  the  Laclirymal  Apparatus,  "  Lancet,"  1863,  vol.  2, 
p.  697. 


614  DISEASES  OF  THE  LACHRYMAL  APPARATUS. 

If  the  inflammatory  symptoms  are  but  moderate,  the  sensitiveness  is 
much  less  marked,  and  on  exerting  a  certain  degree  of  pressure,  we 
may  be  able  to  press  out  a  small  quantity  of  pus  through  the  puncta,  or 
it  may  pass  down  the  nasal  duct.  The  swelling  and  thickening  of  -the 
lining  membrane  of  the  passages  may,  however,  be  so  considerable,  as 
to  prevent  the  exit  of  any  discharge.  Moreover,  the  opening  into  the 
sac  may  have  become  somewhat  displaced,  on  account  of  the  swelling  of 
the  lining  membrane  and  the  enlargement  of  the  cavity  of  the  sac,  and 
thus  offer  another  obstacle  to  the  escape  of  the  contents. 

But  when  the  inflammatory  swelling  has  somewhat  subsided,  and 
the  size  of  the  ducts  is  thus  increased,  the  discharge  may  often  be 
very  freely  squeezed  out  of  the  puncta,  welling  up  at  the  inner  angle 
of  the  eye  and  flowing  over  the  lid.  Together  with  the  pain,  the 
patient  exjjeriences  a  feeling  of  dryness  and  weight  in  that  side  of  the 
nose ;  and  if  the  disease  has  been  preceded  by  blenorrhoea  of  the  sac, 
or  a  stricture  in  the  lachrymal  passages,  there  is  always  a  distinct 
history  of  the  pre-existence  of  a  more  or  less  considerable  and  obstinate 
epiphora.  In  the  acute  inflammation  of  the  sac,  the  onset  of  the 
disease  is  generally  very  rapid  and  intense,  reaching  its  acme  in  the 
course  of  a  few  days.  It  may,  however,  be  more  protracted  and  chronic 
in  its  course,  and  all  the  inflammatory  symptoms  be  less  marked  and 
severe.  If  the  disease  is  left  to  itself,  we  find  that  the  swelling  gains 
in  size,  the  skin  over  it  becomes  thinner  and  thinner,  a  distinct  feeling 
of  fluctuation  is  experienced,  and  finally,  the  abscess  makes  a  sponta- 
neous opening  thi'ough  the  skin,  and  a  considerable  amount  of  pus 
escapes.  The  perforation  is  rapidly  followed  by  a  great  diminution  in 
the  intensity  of  the  inflammatory  symptoms.  For  some  time,  matter 
will  continue  to  ooze  out  through  the  opening,  but  finally,  the  latter 
may  close  and  cicatrize  firmly,  and  the  disease  become  cured ;  or  there 
may  remain  a  chronic  inflammation  of  the  sac,  which  often  proves  very 
obstinate  and  intractable.  Fresh  inflammatory  exacerbations  may 
supervene,  pus  be  again  collected,  and  thus  a  relapse  take  place.  In 
rare  instances,  the  inflammation  is  so  severe  as  to  destroy  the  lining 
membrane  of  the  sac,  and  the  latter  may  thus  become  obliterated.  Or 
again,  the  aperture  in  the  skin  may  scab  over,  pus  become  again  col- 
lected in  the  sac,  and  force  its  way  once  more  through  the  opening ; 
this  perhaps  occurring  again  and  again,  until  finally  a  fistulous 
opening  is  left,  through  which  a  thin  muco-purulent  discharge  and  the 
tears  constantly  ooze.  In  yet  other  cases,  the  sac  may  undergo  ulcera- 
tion at  one  point,  and  the  matter  escape  into  the  neighbouring  cellular 
tissue,  thus  giving  rise  to  a  secondary  sac  or  pouch,  perforation  may 
finally  take  place,  and  a  fistulous  opening  be  established,  leading 
(perhaps  by  a  long  track)  into  this  deverticulum.  In  some  instances, 
there  are  several  such  pouches  bui'rowing  beneath  the  skin  in  different 


INFLAMMATION  OP  THE  LACHEYMAL  SAC.        615 

directions.     They  are,  however,  generally  only  met  with  in  the  chronic 
form  of  dacryocystitis. 

Inflammation  of  the  lachrymal  sac  is  often  due  to  an  extension  of 
the  inflammation  of  the  mucous  lining  of  the  nostril  to  the  nasal  duct 
and  the  sac,  or  downwards  from  the  conjunctiva  and  canaliculus. 
Hence,  it  may  supervene  upon  nasal  catarrh,  or  conjunctivitis  (more 
especially  the  granulai"  form).  It  may  also  follow  blenorrhoea  of  the 
sac.  Periostitis  and  caries  of  the  nasal  bones,  more  especially  in 
persons  of  a  scrofulous  or  syphilitic  diathesis,  may  likewise  produce  it. 
It  sometimes  occurs  as  a  primary  afiection,  being  then  generally  due  to 
exposm^e  to  cold  and  wet.  It  is  often  stated  that  erysipelas  is  a 
frequent  cause,  but  it  would  rather  appear  that  the  latter  disease  is  the 
effect,  and  not  the  cause. 

Our  chief  effort  in  treating  these  cases  must  be  directed  towards  the 
establishment  of  a  free  and  ready  exit  for  the  discharge.  This  is  best 
done  by  dividing  the  punctum  and  canaliculus  quite  into  the  sac.  If 
the  opening  into  the  latter  is  somewhat  contracted,  I  am  in  the  habit  of 
di\ading  the  upper  canaliculus  with  Weber's  knife,  and  then  passing 
the  latter  into  the  sac,  and  freely  incising  its  neck.  In  this  way  a 
very  free  opening  is  obtained,  through  which  the  contents  of  the  sac 
can  be  readily  emptied,  for  a  slight  pressure  upon  the  latter  will  suffice 
to  cause  the  escape  of  the  pus.  A  probe  may  then  be  passed,  so  as  to 
dilate  the  neck  of  the  sac  and  the  nasal  duct.  But  if  the  mucous  lining 
is  much  inflamed  and  swollen,  it  is  wiser  to  abstain  from  too  much 
meddling  and  probing,  as  this  only  tends  to  irritate,  and  excite  fresh 
inflammation.  A  free  exit  having  been  obtained  for  the  discharge,  the 
pain  and  inflammatory  symptoms  soon  subside,  and,  moreover,  all 
danger  of  perforation  is  prevented.  Indeed,  by  at  once  employing  this 
mode  of  treatment,  we  may  often  avert  this  danger,  even  when  the  skin 
over  the  swelling  has  already  become  very  thin.  To  aid  in  allaying 
the  inflammation,  warm  poppy  fomentations,  or  a  leech  or  two  may  be 
apphed.  But  if  the  disease  has  advanced  so  far  that  perforation  is 
imminent,  the  sac  should  be  freely  laid  open  with  a  scalpel,  and  the  pus 
evacuated.  The  incision  should  run  in  a  downward  and  outward 
direction,  and  be  sufficiently  large  to  permit  of  the  ready  escape  of  the 
discharge.  A  narrow  strip  of  lint  should  be  inserted  into  the  sac,  so 
as  to  keep  the  wound  open  for  a  few  days,  and  allow  of  the  draining 
off  of  the  matter.  A  warm  poultice  is  to  be  applied  after  the  operation, 
and  frequently  changed  for  the  first  day  or  two.  When  the  inflam- 
mation has  considerably  abated,  the  canaliculus  should  be  divided 
and  a  probe  passed  into  the  nasal  duct,  so  that  a  free  passage  niay  be 
made  for  the  discharge  and  the  tears.  The  opening  into  the  sac  wdl 
then  soon  close  firmly,  leaving  but  a  very  slight  cicatrix  behind.  To 
hasten  the  cicatrization,  the  edge  of  the  opening  may  be  hghtly  touched 


616  DISEASES  OF  THE  LACHRYMAL  APPARATUS. 

with  sulphate  of  copper.  If  perforation  has  already  taken  place  before 
the  surgeon  was  consulted,  the  canaliculus  and  neck  of  the  sac  should 
be  freely  divided,  and  a  probe  passed.  In  such  cases,  the  edges  of  the 
perforation  are  often  very  ragged  and  granular ;  indeed,  there  may 
even  be  an  ulcerated  opening  of  a  considerable  size.  This  should  be 
touched  with  sulphate  of  copper,  a  probe  be  passed  daily  through  the 
duct,  and  then  the  fistulous  opening  will  soon  be  found  rapidly  to  heal. 
If  any  fistulous  openings  exist  in  connection  with  deverticula,  they 
should  be  freely  laid  open,  and  caused  to  heal  from  the  bottom. 

Should  a  condition  of  chronic  inflammation  of  the  sac,  accompanied 
by  a  muco-purulent  discharge,  persist  for  some  time  after  the  perfora- 
tion is  closed,  and  the  more  acute  inflammatory  symptoms  have  dis- 
appeared, the  sac  should  be  syringed  out  with  an  astringent  lotion. 
Before  employing  this,  it  is  well  to  inject  the  sac  with  water  so  as  to 
flush  out  all  the  discharge,  and  then  a  weak  astringent  injection  (Zinc. 
Sulph.  gr.  ii — iv,  or  Alum  gr.  ij,  Aq.,  dist.  ^j)  should  be  employed.  This 
will  diminish  the  inflammatory  swelling  and  secretion  of  the  lachrymal 
passages.  This  injection  should  be  used  every  day,  or  every  other  day, 
according  to  circumstances,  and  will  generally  soon  produce  very  con- 
siderable improvement.  Its  strength  should  gradually  be  increased. 
Various  kinds  of  syringes  have  been  devised  for  this  purpose,  but  the 
best  is  a  small  graduated  glass  syringe  holding  about  half  an  ounce. 
I  am  in  the  habit  of  employing  one  made  for  me  by  Messrs.  Weiss,  which 
differs  somewhat  from  that  in  ordinary  use.  The  instrument  consists 
of  two  separate  parts,  the  canula  and  the  syringe. 

The  silver  canula  is  of  the  size  of  Bowman's  ISTo.  6  probe,  and  is 
about  three  inches  in  length.  At  the  top  is  a  cross  bar,  by  which  it  can 
be  easily  held  and  directed,  and  beyond  this  bar  is  a  portion  of  india- 
rubber  tubing  about  l|-inch  in  length,  ending  in  a  silver  mount 
into  which  the  nozzle  of  the  syringe  fits  firmly.  The  advantage  of  the 
india-rubber  tubing  is,  that  when  the  canula  is  passed  quite  down  into 
the  nasal  duct,  the  patient  can  lean  forward  with  his  face  over  a  basin, 
and  the  surgeon,  standing  in  front  of  the  patient,  can  bend  the  india- 
rubber  tube  forward  to  the  necessary  extent,  and  readily  insert  the 
nozzle  of  the  syringe,  and  thus  inject  the  fluid  without  any  difficulty. 
Whereas,  with  the  ordinary  silver  canula  it  is  often  diflicult  to  do  so, 
on  account  of  the  prominence  of  the  brow.  The  fitting  of  the  nozzle 
into  the  canula  by  a  plain  mount  is  much  better  than  by  a  screw, 
because  if  the  screw  sticks  a  little,  or  the  patient  is  restless,  the  lining 
membrane  of  the  lachrymal  passages  may  easily  be  bruised  in  the  endea- 
vour to  screw  the  nozzle  on.  The  instrument  is  to  be  used  in  the 
following  manner  : — The  canula  is  to  be  passed  down,  by  the  upper  or 
lower  canaliculus,  thi'ough  the  sac  into  the  nasal  duct,  and  allowed  to 
rem,ain  there  for  five  or  ten  minutes,  so  as  to  dilate  the  passage.     The 


BLENORRHCEA   OF   THE   SAC.  617 

patient  being  then  directed  to  lean  his  face  well  forward  over  a  basin, 
the  nozzle  of  the  syringe  is  gently  inserted  into  the  canula,  and  the 
flnid  slowly  injected,  which  will  flow  ont  through  the  nostril  into  the 
basin.  Whilst  injecting,  the  surgeon  should,  with  his  left  hand,  seize 
the  canula  by  the  cross  bar,  and  slowly  withdraw  it,  so  that  the  fluid 
may  come  in  contact  with  every  part  of  the  duct  and  sac.  The  first 
injection  should  consist  of  water,  in  order  to  wash  away  the  discharge, 
the  canula  should  then  be  re-introduced,  and  the  astringent  injection  be 
used.  Mr.  Bowman  employs  a  small  india-rubber  ball  syringe,  but 
the  stream  from  this  is  often  too  weak  to  force  its  way  through,  if  the 
lining  membrane  of  the  sac  and  duct  is  greatly  swollen,  or  the  stricture 
very  firm.  If  the  case  proves  very  obstinate,  and  the  patient  cannot 
possibly  submit  to  a  lengthened  course  of  treatment,  and  is  yet 
anxiously  desirous  to  be  relieved  of  the  complaint,  it  may  be  necessary 
to  destroy  the  sac,  but  such  a  course  should  only  be  followed  in  very 
rare  and  exceptional  instances.  I  shall,  however,  return  to  this  subject 
when  treating  of  blenorrhoea,  and  of  obstinate  strictures  of  the  duct 
and  sac. 

4.— BLENORRHCEA  OF  THE  SAC  (MUCOCELE). 

This  disease  is  often  developed  very  slowly  and  insidiously,  coming 
on  without  the  patient  being  almost  aware  that  there  is  anything  the 
matter,  except  perhaps  a  little  epiphora,  and  a  slight  and  occasional 
swelling  in  the  region  of  the  lachrymal  sac,  accompanied,  if  the  latter 
is  pressed,  by  a  little  oozing  out  of  turbid,  viscid  discharge,  which, 
passing  over  the  cornea,  dims  the  sight.  The  swelling  of  the  sac 
varies  considerably  in  size  and  hardness.  It  is  generally  elastic  and 
firm,  and  the  skin  somewhat  red ;  on  squeezing  out  the  discharge,  the 
tip  of  the  finger  sinks  a  little  into  the  skin.  The  distension  of  the  sac 
undergoes  considerable  alterations,  varying  with  the  changes  in  the  tem- 
perature, and  the  exposure  to  which  the  patient  subjects  himself.  As 
long  as  the  weather  is  warm  and  dry,  the  patient  may  be  quite  free 
from  any  trouble,  but  as  soon  as  he  exposes  himself  to  a  cold  bleak 
wind  or  a  damp  atmosphere,  the  sac  becomes  inflamed  and  swollen,  the 
eye  is  watery,  and  on  pressure  upon  the  sac,  a  copious  discharge 
wells  up  through  the  puncta.  The  frequent  recurrence  or  long  exist- 
ence of  this  condition,  leads  to  a  thickened  and  villous  state  of  the 
lining  membrane  of  the  sac  and  ducts,  and  the  secretion  becomes  more 
thick  and  muco-purulent  in  character.  If  it  constantly  regurgitates 
through  the  puncta,  these  and  the  canaliculi  may  become  somewhat 
dilated.  Stricture  of  some  part  of  the  nasal  duct,  or  of  the  canaliculus 
near  its  opening  into  the  sac,  if  it  has  not  already  occm'red,  will 
generally  soon  supervene. 

In  some  cases,  the  sac,  instead  of  being  thickened  and  hypertrophied, 


618  DISEASES   OF   THE   LACHRYIIAX,   APPARATUS. 

becomes  thinned  and  greatly  distended  ;  Toeing  filled  with  a  thin,  glairy, 
viscid  fluid  which  flows  down  the  nasal  duct,  or  oozes  up  through  the 
puncta. 

Blenorrhoea  of  the  lachrymal  sac  is  almost  always  met  with  as  a 
secondary  affection,  being  ofcen  consecutive  upon  an  inflammation  of 
the  Schneiderian  membrane,  which,  ascending  along  the  nasal  duct, 
has  reached  the  sac.  Hence  nasal  catarrh,  and  periostitis  or  caries  of 
the  nasal  bones  are  not  unfrequent  causes  of  the  disease.  Or  it  may 
supervene  upon  inflammation  of  the  conjunctiva  (more  especially 
granular  ophthalmia),  or  of  the  edge  of  the  hd.  Malposition  or  con- 
traction of  the  puncta,  or  a  narro\Nang  or  stricture  df  the  lachrymal 
canal  also  often  produce  it.  Indeed,  obstructions  in  the  lachrymal 
passages,  either  above  or  below  the  sac,  are  very  fruitful  sources  of 
blenorrhoea.  This  disease  is  therefore  often  met  with  in  cases  in 
which  there  is  a  narrowing,  obliteration,  or  eversion  of  the  puncta ;  or 
a  contraction  or  stricture  of  the  canaliculus  or  of  the  nasal  duct,  which 
m.ay  be  due  to  inflammatory  swelUng  of  the  lining  membrane,  or  to 
presence  of  cicatrices.  Polypi  or  other  growths,  which  by  compression 
narrow  or  obstruct  the  duct,  may  also  give  rise  to  it.  Persons  in 
whom  the  root  of  the  nose  is  very  flat  and  broad,  and  the  eyes  far 
apart,  are  very  subject  to  diseases  of  the  lachrymal  apparatus,  on 
account  of  the  diminution  of  the  antero-posterior  diameter  of  the 
duct.  But  the  same  thing  may  occur,  as  Arlt  and  Wecker  point 
out,  if  the  nose  is  very  prominent  and  narrow,  so  that  the  passage 
is  much  narrowed  laterally.  Blenorrhoea  of  the  sac  often  super- 
venes upon  acute  inflammation  of  the  latter,  which,  after  having  per- 
haps caused  repeated  perforation  and  escape  of  the  discharge,  passes 
over  into  a  state  of  chronic  inflammation,  accompanied  by  a  thinnish 
muco-purulent  discharge.  Acute  inflammatory  exacerbations  recur 
every  now  and  then,  and  a  more  or  less  extensive  and  firm  stricture 
of  the  lachrymal  or  nasal  duct  is  almost  always  present. 

Only  in  very  rare  instances  do  we  find  that  the  disease,  if  left  to 
itself,  undergoes  any  considerable  or  permanent  improvement,  much 
less  a  cure.  For  even  in  spite  of  the  best  and  most  patient  treatment, 
it  often  proves  very  obstinate  and  intractable.  The  lining  membrane 
of  the  sac  and  duct  becomes  hypertrophied  and  swollen,  and  often 
undergoes  extensive  cicatricial  changes,  being  transformed  into  a  fibro- 
tendinous  tissue,  and  the  discharge  becoming  thin,  glairy,  and  viscid, 
or  in  some  cases  of  a  thick  gluey  character  (Stellwag). 

Strictures  of  the  lachrymal  passages  vary  very  considerably  in  extent, 
firmness,  and  situation.  Their  most  frequent  seat  is  the  point  where 
the  canaliculi  open  into  the  sac,  or  where  the  latter  passes  into  the 
nasal  duct;    but  they  may  also  be  situated  at  a  lower  pai't  of  the 


BLENORRHCEA   OF  THE   SAO.  619 

duct,  and  hence  the  necessity  of  always  passing  the  probe  through  the 
whole  length  of  the  latter,  in  order  that  we  may  ascertain  whether  any 
stricture  exists  at  its  lower  portion.  If  the  stricture  be  due  to  a 
thickened,  swollen  condition  of  the  lining  membrane,  and  if  it  be  con- 
siderable in  extent,  it  will  oppose  a  certain  degree  of  obstruction  to  the 
passage  of  the  probe,  and  will  embrace  the  latter  firmly  and  closely,  but 
will  yield  to  the  gentle  yet  steady  pressure  of  the  probe.  The  dense 
cicatricial  stricture  affords  a  more  obstinate  resistance,  and  it  may  be 
difficult  to  pass  even  a  very  small  probe,  without  employing  a  consider- 
able degree  of  force.  The  symptoms  to  which  a  stricture  gives  rise,  are, 
epiphora,  blenorrhoea  or  inflammation  of  the  sac,  and  a  glairy,  viscid 
or  muco-purulent  discharge. 

The  first  and  fundamental  principle  in  the  treatment  of  blenorrhoea 
of  the  sac  and  stricture  of  the  lachrymal  passages  is,  to  divide  one  or 
both  puncta  and  canaliculi,  and  to  pass  a  probe  down  through  the  nasal 
duct.  The  mode  of  dividing  the  puncta  and  the  canaliculi  has 
been  already  described.  The  probes  which  are  best  adapted  for  cathe- 
terization, are  those  of  Mr.  Bowman,*  which  are  made  of  silver,  and  of  six 
difierent  sizes.  No.  1  is  very  small,  like  a  fine  hair  probe  ;  No.  6  is  about 
■jJg-  of  an  inch  in  diameter.  Mr.  Teale  Pridgin,  of  Leeds,  recommends 
a  bulbed  probe,  which  is  also  preferred  by  Mr.  Critchett,t  who  thinks 
that  it  passes  more  readily,  and  is  less  apt  to  lacerate  the  mucous 
lining,  or  to  make  a  false  passage.  I,  as  a  rule,  use  Mr.  Bowman's 
probes,  but  frequently  employ  a  considerably  larger  size  than  No.  6. 
The  instrument  is  to  be  introduced  in  the  following  manner : — The  end 
of  the  probe  having  been  slightly  bent,  so  that  it  may  pass  more  readily 
forward  into  the  nasal  duct,  its  point  should  be  inserted  vertically  into 
the  lower  punctum,  the  skin  being  at  the  same  time  put  on  the  stretch, 
and  then  passed  horizontally  along  the  opened  canaliculus  until  its 
extremity  reaches  the  inner  wall  of  the  sac,  which  is  easily  recognised 
by  its  presenting  a  hard,  bony  obstruction  to  the  probe.  The  latter  is 
then  to  be  turned  vertically,  the  convexity  of  the  bend  looking  back- 
wards, and  slowly  and  gently  passed  into  the  sac ;  when  the  latter  is 
gained,  the  direction  of  the  instrument  must  be  slightly  altered,  the 
point  being  directed  soraewhat  outwards  and  forwards,  so  that  ifc  may 
readily  pass  into  the  nasal  duct,  through  which  it  is  to  be  pushed  until 
it  reaches  the  floor  of  the  nose.  When  the  lining  membrane  of  the  sac 
and  of  the  duct  is  much  swollen  and  hyper trophied,  it  is  sometimes 
rather  difficult  to  find  this  entrance,  as  it  may  be  somewhat  displaced 
or  contracted,  or  more  or  less  covered  by  a  small  fold  of  the  mucous 
membrane,  which  thus  forms  a  little  valve  over  it.  If,  after  some 
careful  searching,  we  do  not  succeed  in  finding  the  opening  into  the  nasal 

*  "  R.  L.  0.  H.  Rep.,"  i,  10.  f  "Lancet,"  186i,  vol.  i,  147. 


620  DISEASES   OF   THE   LACHRYMAL   APPARATUS. 

duct,  it  is  better  to  withdraw  tlie  probe  and  to  wait  for  a  day  or  two 
■until  the  inflammatory  swelling  has  subsided,  than  to  attempt  to  force 
the  passage  of  the  probe  ;  for  this  may  not  only  produce  severe  lacera- 
tion of  the  membrane,  but  lead  to  the  formation  of  a  false  passage; 
or  the  probe  should  be  withdrawn,  its  curvature  somewhat  altered,  and 
then  be  again  inserted,  in  the  hopes  of  finding  the  aperture.  The  first 
probe  that  is  passed  should  only  be  of  medium  size  (No.  3  or  4  of 
Bowman),  but  if  the  stricture  is  very  considerable,  No.  2,  or  even 
No.  1,  may  have  to  be  tried  before  it  can  be  passed.  The  instrument 
should  be  allowed  to  remain  in  the  duct  for  five  or  ten  minutes,  and 
then  gently  withdrawn,  and  this  catheterization  should  be  repeated 
every  day  or  every  other  day,  according  to  the  exigencies  of  the  case. 
The  size  of  the  probe  should  be  increased  until  we  arrive  at  No.  6. 
If  the  probe  is  arrested  at  the  point  where  the  canaliculi  join  the  sac, 
the  skin  near  the  tendo  oculi  will  be  moved  with  the  movement  of  the 
probe,  and  an  elastic  obstruction  be  felt ;  whereas,  when  the  instrument 
has  entered  the  sac,  the  skin  does  not  wrinkle  or  move. 

The  sac  often  becomes  considerably  diminished  in  size,  and  its 
walls  thinned,  if  on  account  of  displacement  of  the  puncta,  or  stricture 
of  the  canaliculi,  the  sac  has  been  empty  for  a  very  long  period.  We 
then  find  great  difficulty  in  introducing  the  probe  into  the  sac,  as  it 
repeatedly  slips  out  again.  In  many  cases,  it  sufiices  to  open  the  lower 
canaliculus  and  to  pass  the  probe  through  it ;  in  others  it  may  be  neces- 
sary also  to  divide  the  upper  one.  This  is  more  especially  the  case  if 
we  desire  to  get  a  very  free  opening  into  the  sac,  to  pass  an  extra  sized 
probe,  or  if  there  exists  any  stricture  at  the  entrance  of  the  sac, 
where  the  canalicuh  open  into  it.  If  the  latter  be  the  case,  I 
prefer  to  open  the  upper  punctum  and  canaliculus  with  Weber's  beak- 
pointed  knife,  the  point  of  which  should  then  be  passed  quite  down  into 
the  sac,  and  the  internal  palpebral  ligament  freely  divided  sub- 
cutaneously.  In  doing  so,  the  slightly  convex  cutting  edge  of  the 
blade  should  be  turned  forwards  and  outwards,  and  the  internal 
palpebral  ligament  divided  subcutaneously,  with  a  slightly  sawing 
m.ovement.  It  will  be  felt  to  grate  a  little,  and  its  division  is  followed 
by  more  or  less  copious  bleeding.  This  having  been  done,  a  probe 
should  be  passed  down  to  ascertain  the  exact  situation,  nature,  and 
extent  of  any  existing  stricture.*  Weber  uses  for  this  purpose 
a  graduated  bi-conical  sound,  which  increases  very  rapidly  in  size 
from  the  point  upwards.  This  is  to  be  forced  through  the  stricture, 
if  the  latter  readily  yields ;  if  this  is  not  the  case,  but  the  lining 
membrane  is  much  swollen  and  inflamed,  it  is  better  to  jDostpone  the 
probing  for  a  few  days,  until  the  inflammatory  swelling  has  subsided, 

*  Vide  Weber's  articles  on  Diseases  of  tlie  Lachrymal  Apparatus,  "  A.  f.  0.," 
viii,  1,  107;  aud  "XI.  Mouatsbl.,"  18G3. 


BLENORRHCEA   OF   THE   SAO.  (521 

to  hasten  which  end,  injections  of  water  and  of  astringent  lotions  are  to 
be  employed.  The  internal  palpebral  ligament  may  also  be  divided  with 
Bowman's  cannla  knife ;  the  upper  canaliculus  is  to  be  freely  divided, 
and  then  the  point  of  the  knife  is  to  be  passed,  sheathed,  into  the  sac, 
the  sheath  withdrawn,  and  the  Hgament  divided  subcutaneously ;  or 
the  director  and  cataract  knife  may  be  used.  Weber's  knife  will,  how- 
ever, be  found  more  convenient  for  this  purpose.  The  opening  into 
the  sac  may  also  be  widened  with  Bowman's  dilator,  the  blunt  blades 
of  which,  in  separating  like  those  of  scissors,  dilate  the  opening  into 
the  sac. 

For  some  years  past,  bougies  of  laminaria  digitata  have  been 
used  by  several  surgeons  of  eminence.  They  were  first  introduced 
for  this  purpose  by  Mr.  Couper,  and  have  been  extensively  employed 
by  him  and  Mr.  Critchett.  I  have  also  often  used  them  with  marked 
success  in  cases  of  very  obstinate  stricture.  Their  peculiar  advantage 
consists  in  theu'  imbibing  the  fluid  in  the  lachrymal  passages, 
and  swelling  up  to  double  and  treble  their  original  size.  But  there 
is  the  danger  that  they  may  swell  up  to  such  an  extent  beyond  the  point 
of  stricture,  that  the  dilated  bulbous  part  can  only  be  di'awn  back 
through  the  stricture  at  the  expense  of  much  contusion  or  even 
laceration  of  the  lining  membrane  at  this  point,  or,  what  is  still  worse, 
that  in  the  great  effort  to  extract  the  probe  it  may  break  short,  and 
necessitate  its  excision.  The  best  mode  of  obviating  these  difficulties, 
and  yet  at  the  same  time  to  produce  a  slow  and  gradual  dilatation,  is 
to  draw  back  the  probe  a  very  little  at  intervals  of  a  minute  or  so,  in 
order  that  it  may  not  have  time  to  swell  up  considerably,  below 
the  stricture.  By  this  gradual  retraction,  the  latter  will,  moreover, 
be  gently  dilated  by  the  enlarging  probe.  By  pursuing  this  method, 
and  by  always  being  extremely  careful  to  use  these  probes  with 
delicacy  and  gentleness,  I  have  found  great  benefit  from  their  employ- 
ment. Their  use,  however,  requires  so  much  supervision,  that  it 
is  somewhat  difficult  to  find  sufficient  time  in  hospital  practice ;  where 
the  patients  are  so  numerous,  that  one  may  easily  forget  to  withdraw 
the  probe  a  little  at  short  intervals,  and  let  it  swell  up  too  much.  In 
order  to  limit  the  dilatation  to  the  point  of  stricture,  the  rest  of 
the  bougie  may  be  covered  with  copal  varnish. 

If  the  blenorrhoea  proves  obstinate,  and  the  discharge  as  well  as 
the  swelling  of  the  sac  and  duct  continue,  great  benefit  is  found  from 
the  systematic  use  of  astringent  injections,  of  sulphate  of  zinc,  alum, 
or  acetate  of  lead.  Their  strength  must  vary  according  to  the  amount 
and  nature  of  the  discharge  and  the  degree  of  swelling  of  the  lining 
membrane.  Before  their  use,  the  sac  must  be  washed  out  with  an 
injection  of  water.  The  patient  should  also  be  directed  frequently  to 
press  out  the  discharge,  for  if  it  is  allowed  to  accumulate  in  the  sac 


622  DISEASES   OF   THE   LACHRYMAL  APPARATUS. 

and  to  become  decomposed,  it  proves  a  source  of  considerable  irritation, 
and  may  even  set  up  acute  inflammation  of  the  sac. 

Dr.  Stilling  of  Cassel,  has  devised  a  cure  for  strictures  of  the 
lachrymal  passages  by  internal  incision.*  The  punctum  having  been 
divided,  he  passes  down  a  probe  and  finds  the  exact  seat  of  the  stric- 
ture, then  withdraws  the  probe  and  passes  down  his  knifef  (Fig.  86) 
to  the  stricture,  and  divides  it  in  three  or  four  directions. 
Fig.  86.  This  having  been  done,  he  withdraws  the  knife,  re-introduces 
the  probe,  and,  if  another  stricture  is  found  further  down, 
also  divides  this.  Dr.  Warlomont,  in  a  very  recent  article  in 
the  "  Annales  d'Oculistique,"  J  speaks  in  the  warmest  terms 
of  his  great  and  immediate  success  with  this  operation,  and 
recites  several  cases.  He  operates  in  the  following  manner : — 
The  upper  punctum  having  been  divided  with  Weber's  knife, 
he  next  passes  Weber's  bi-coniv?al  sound  down  into  the  nasal 
duct,  and  leaves  it  there  for  a  few  minutes.  On  its  removal, 
he  immediately  passes  Stilling's  knife  completely  down  into  the 
nasal  duct,  so  that  its  whole  blade  disappears,  and  then  incises 
the  duct  in  three  or  four  dii^ections,  until  the  knife  can  be 
turned  quite  freely  in  all  directions.  No  dilator  or  probe  is 
introduced  after  the  operation ;  and,  according  to  Stilling  and 
Warlomont,  even  severe  and  obstinate  cases  are  thus  imme- 
diately and  permanently  cured.  The  favourable  action  of  this 
operation  appears  to  be  chiefly  due  to  its  affording  a  very  free  exit  to 
the  contents  of  the  sac. 

Dr.  Herzenstein  proposes  the  forcible  dilatation  of  the  stricture,  on 
the  principle  of  Mr.  Barnard  Holt's  dilatation  of  stricture  of  the  urethra. 
We  sometimes  find  that  the  alterations  in  the  lining  membrane  of 
the  sac  are  so  great,  that  they  persist  even  after  the  passage  of  the  tears 
is  unobstructed  ;  and  then  it  may  be  necessary  to  have  recourse  to  some 
direct  treatment  of  the  sac.  Thus,  if  the  latter  is  not  only  much  dilated, 
but  also  thickened  and  secreting  much  muco-purulent  discharge, 
Mr.  Bowman  has  dissected  out  the  anterior  half  of  the  thickened  sac. 
Mr.  Critchett  has  treated  such  cases  successfully  by  laying  open  the  sac, 
and  destroying  a  portion  of  the  interior  with  potassa  cum  calce.     As 

*  Vide  Ur.  Stilling's  brochure,  "  Ueber  die  Heilung  der  Verengertmgen  der 
Thriinenwege  mittelst  der  Innern  Licision."     Cassel,  1868. 

t  The  blade  of  this  knife  is  13  mm.  long,  3  mm.  broad  nearest  the  handle,  and 
gradually  narrows  down  to  f  mm.  at  the  point,  which  is  somewhat  rounded  but 
cutting.  The  blade  passes  over  into  a  flat  stem,  which  is  about  the  size  of  Bowman's 
largest  probe,  and  is  attached  to  the  handle.  The  back  of  the  blade  should  be 
made  strong  and  i-athcr  wedge-shaped,  and  its  temper  shoidd  not  be  too  fine,  other- 
wise, it  may  easily  break  or  a  portion  of  it  chip  olf,  in  forcing  it  through,  or  in 
incising  the  stricture,     This  knife  may  be  obtained  of  Messrs.  Weiss. 

I  "Annales  d'Oculistique,"  Oct.,  1868. 


BLENORRHCEA   OF   THE   SAO.  623 

this  condition  of  the  lining  membr<ane  of  the  sac,  as  well  as  the  con- 
siderable dilatation  of  the  latter,  are  to  a  great  extent  maintained  and 
increased  by  the  constant  flow  of  the  tears  into  the  sac,  Weber*  has 
remedied  this  by  producing  an  eversion  of  the  punctum,  so  that  the 
tears  cannot  flow  into  the  canaliculus ;  thus  causing  them  to  collect 
in  the  little  reservoir,  formed  by  the  lower  lid  being  slightly  turned 
away  from  the  eyeball.  He  gains  this  end,  by  passing  a  needle,  armed 
with  a  stout  thread,  through  the  skin  and  muscle  close  to  the  punctum, 
and  bringing  it  out  again  a  little  further  inwards,  so  as  to  embrace  the 
punctum  and  a  small  fold  of  the  skin  within  the  suture,  which  is  to  be 
tightly  knotted.  This  will  readily  produce  a  slight  ectropium,  and 
the  beneficial  effect  of  preventing  the  entrance  of  the  tears  into  the 
lachrymal  sac,  will  generally  be  already  evident  within  24  hours 
afterwards.  I  have  sometimes  gained  great  benefit  in  such  cases  from 
the  application  of  a  firm  compress  bandage  over  the  sac,  which  pre- 
vents the  entrance  of  the  tears.  This  mode  of  treatment  is  also  of 
great  use  in  those  cases  in  which  the  sac  is  much  thinned  and  dilated, 
and  secretes  a  large  quantity  of  thin  glairy  discharge.  Mr.  Critchettf 
has  devised  an  ingenious  little  truss,  so  as  to  keep  up  a  gentle  and  con- 
tinuous pressure. 

If  the  stricture  is  very  firm  and  dense,  and  there  is  much  tendency 
for  it  to  close  after  the  removal  of  the  probe,  a  style  may  be  passed  into 
the  duct  by  the  slit  canaliculus,  and  left  in  for  a  few  days.  The  upper 
portion  is  to  be  very  tbin  and  bent  at  a  very  acute  angle,  so  as  to  be 
bent  over  the  lower  lid,  thus  keeping  the  other  portion  in  situ.  The  bent 
portion  may  also  be  made  so  thin  and  small,  that  it  will  lie  along  the 
opening  made  in  the  lower  punctum,  and  thus  be  in\asible.  Mr.  Bow- 
man first  introduced  this  mode  of  treatment,  and  it  is  often  attended 
with  success,  but  in  some  cases,  the  style  sets  wp  a  considerable  degree 
of  irritation,  and  may  even  give  rise  to  ulceration  if  it  is  left  in  too 
long.  The  size  of  the  style  should  be  gradually  increased  as  the 
stricture  yields,  until  it  has  attained  dimensions  considerably  larger 
than  Bowman's  probe  No.  6.  Dr.  Seeley  of  Cincinnati  informs  me, 
that  he  uses  this  mode  of  treatment  to  a  very  considerable  extent,  and 
witb  marked  success.  The  old-fashioned  style,  which  used  to  be  inserted 
into  th.e  nasal  duct  through  an  external  opening  in  the  sac,  has  fallen 
into  well-merited  and  almost  entire  disuse. 

In  very  severe  and  obstinate  cases  of  chronic  inflammation  of  the 
sac,  accompanied  perhaps  by  ulceration  and  periostitis,  and  a  severe 
stricture  or  even  closure  of  the  duct,  cases  wliicli  resist  every  mode  of 
treatment  and  prove  a  gi'eat  and  constant  source  of  annoyance  and 


*  "  Kl.  Monatsbl."  1865,  106. 

t  Lectures  on  Diseases  of  Lachrymal  Apparatus,  "Laucet,"  1864,  1,  14S. 


624  DISEASES  OP  THE  LACHRYMAL  APPARATUS. 

trouble  to  tlie  patient,  it  may  be  necessary  to  obliterate  the  sac.  This 
is  also  indicated  if  the  patient  cannot  remain  under  medical  treatment 
for  a  sufficient  length  of  time  to  lead  to  any  reasonable  hope  of  benefit 
by  the  usual  mode  of  treatment,  and  is  yet  very  anxious  to  be  relieved 
from  this  very  troublesome  affection.  This  mode  of  treatment  should, 
I  think,  be  only  adopted  in  very  exceptional  cases,  which  have  resisted 
every  other  means  of  treatment.  For  it  is  surprising  what  a  degree 
of  improvement  may  often  be  attained  by  treating  these  cases  with 
patience  and  care,  although  it  must  be  confessed  that  a  very  long  time 
is  but  too  frequently  required  before  much  improvement  takes  place. 
Obliteration  of  the  sac  is,  moreover,  only  indicated  if  the  natural  secre- 
tion of  the  tears  is  not  considerable,  so  that  they  are  nearly  entirely 
carried  off  by  evaporation,  otherwise,  great  and  annoying  epiphora 
remains  after  the  destruction  of  the  sac. 

Various  methods  of  destroying  the  sac  have  been  devised  and  recom- 
mended. At  one  time,  the  actual  cautery  was  extensively  employed  for 
this  purpose,  but  lately  the  gal vano- caustic  apparatus  has  been  largely 
substituted  for  it.  The  sac  is  to  be  opened  by  a  free  incision,  which  is 
to  extend  likewise  through  the  tendo-oculi  into  the  upper  portion  of  the 
sac,  which  forms  a  cul  de  sac  above  the  tendon,  and  thoroughly  cleansed 
out.  When  the  haemorrhage  has  ceased,  the  lips  of  the  wound  are  to 
be  kept  apart  by  Manfredi's  speculum,  which  is  moreover  provided 
with  side  plates  to  prevent  the  cheek  from  being  burnt.  Instead  of 
the  actual  cautery  or  the  galvano- caustic  apparatus,  various  caustics 
are  often  employed,  e.g.,  nitrate  of  silver,  butter  of  antimony,  potassa  c. 
calce,  perchloride  of  iron,  etc.  I  myself  prefer  the  nitrate  of  silver, 
which  I  first  saw  employed  for  this  purpose  with  great  success  by 
Von  Graefe.  It  is  easily  manageable,  very  safe,  and  leaves  the 
smoothest  and  least  unsightly  cicatrix  of  any  caustic.  Before  attempt- 
ino-  to  destroy  the  sac,  the  puncta  and  canaliculi  must  always  be  first 
obliterated,  so  as  to  stop  the  entrance  of  tears  into  the  sac,  other- 
wise their  admission  will  prevent,  or  at  least  greatly  retard,  the 
adhesive  inflammation  and  obliteration  of  the  sac.  The  best  method 
of  closing  the  puncta  and  canaliculi  is  to  pass  into  them  a  very  fine 
probe,  coated  with  nitrate  of  silver,  or  a  thin  hot  wire,  which  will  set 
up  adhesive  inflammation,  thus  obliterating  the  puncta,  and  closing  the 
canaliculi.  When  this  end  has  been  obtained,  the  sac  must  be  laid 
open  to  its  whole  extent  by  a  free  incision,  thoroughly  cleansed  out, 
and  when  the  bleeding  has  entirely  ceased,  the  walls  of  the  sac  should 
be  touched  with  nitrate  of  silver.  Cold  compresses  should  be  applied 
to  diminish  the  inflammatory  symptoms.  The  nitrate  of  silver  should 
be  repeated  several  times,  at  intervals  of  about  two  days,  before  the 
epithelium  is  formed.  Or  at  the  end  of  forty-eight  hours  the  thick 
eschar  should  be  completely  removed,   and  a  small  firm  compress  be 


FISTULA   OF   THE  LACHRYMAL   SAC,   ETC.  625 

applied  to  the  sac,  so  as  to  bring  its  raw  surfaces  together,  a  firm 
bandage  being  placed  over  the  compress,  in  order  to  keep  it  in  situ. 

At  the  Ophthalmological  Congress,  held  at  Heidelberg  this  autumn. 
Dr.  Berlin  narrated  several  cases  of  very  obstinate  and  severe  disease  of 
the  sac,  in  which  he  obtained  a  successful  result  by  extirpation  of  the 
latter. 

In  severe  and  intractable  cases  of  epiphora,  inflammation  of  the 
sac,  etc.,  the  extirpation  of  the  lachrymal  gland  has  been  strongly 
urged  by  several  surgeons,  more  especially  by  Mr.  Zachariah  Laurence,* 
who  has  practised  it  extensively ;  it  has  also  been  employed  by 
Mr.  Carter,  Dr.  Taylor,  Mr.  Windsor,  and  others. 

5.— FISTULA  OF  THE  LACHRYMAL  SAC,  ETC. 

By  this  term  is  understood  a  communication  between  the  lachrymal 
sac  or  passages  and  the  external  integument.  I  have  already  men- 
tioned, when  speaking  of  the  inflammation  of  the  sac,  that  after 
spontaneous  perforation  of  the  latter,  a  more  or  less  extensive  fistulous 
opening  may  be  left,  which  may  prove  very  obstinate  and  intractable 
if  there  is  a  very  firm  or  impassable  stricture,  or  considerable  disease 
of  the  bone.  Caries  and  necrosis  of  the  bony  walls  of  the  sac  are  a 
very  frequent  cause  of  fistula.  The  latter,  on  the  other  hand,  is  but 
very  rarely  produced  by  direct  injury,  or  a  wound  of  the  sac.  The 
fistula  may  either  open  directly  into  the  sac,  or  there  may  exist  a 
fistulous  track  of  varying  length.  The  edges  of  the  fistula  may  be  at 
first  swollen,  ii'regular,  and  somewhat  ulcerated,  the  ulceration  perhajis 
extending  to  some  distance  from  the  aperture.  But  after  a  time  it 
contracts  in  size,  its  margin  becomes  smoother,  and  finally,  only  a  very 
minute  opening,  which  hardly  admits  the  finest  probe,  may  be  left,  this 
is  sometimes  termed  capillary  fistula.  If  the  orifice  is  retracted,  and 
its  edges  covered  with  healthy-looking  skin,  the  minute  aperture  may 
be  easily  overlooked,  but  on  pressing  the  sac,  a  small  tear-drop  will  be 
seen  to  exude. 

The  best  treatment  for  lachrymal  fistula  is  that  of  slitting  up  the 
puncta,  dividing  the  internal  palpebral  ligament,  and  passing  a  probe 
down  frequently.  If  the  passage  is  free,  this  will  generally  cause  the 
fistula  to  heal  in  the  course  of  a  few  days.  But  if  the  passage  is 
impermeable,  or  the  disease  of  the  bone  extensive,  it  may  be  necessary 
to  obliterate  the  sac,  or  to  force  the  passage.  The  latter  is  to  be  done 
with  one  of  Bowman's  probes  or  Weber's  dilator.  But  extreme  care 
must  be  taken  to  do  this  with  delicacy,  for  if  rude  force  be  used,  much 
mischief  is  sure  to  accrue.     In  the  capillary  fistula,  the  edges  of  which 

*  Tide  Mr.  Laurence's  article,   "  On  Removal  of  the  Lachrymal  Gland  as  a 
radical  cure  for  Lachrymal  Disease,"  "  Ophthalmic  Review,"  No.  12. 

2  s 


626  DISEASES   OF   THE   LACHRYMAL    APPARATUS. 

are  covered  by  sniooth  skin,  it  is  sometimes  advisable  to  pare  the  edges, 
BO  as  to  m.ake  them,  raw,  and  tben  to  close  the  minute  aperture  with  a 
suture,  which  will  cause  the  opening  to  heal  by  first  intention. 

Polypi  of  the  sac  are  of  rare  occurrence.  They  closely  resemble 
nasal  polypi  in  structure,  and  may  attain  the  size  of  a  small  nut. 
They  give  rise  to  a  peculiar  feeling  of  resilience  and  elasticity  to  the 
finger,  and  although  on  pressure  a  certain  quantity  of  glairy  or  muco- 
purulent fluid  may  be  evacuated,  yet  we  cannot  empty  the  sac  com- 
pletely. On  incising  it,  some  fluid  escapes,  and  the  polypus  (like  a 
gelatinous  mass)  springs  into  the  wound.*  If  the  sac  is  extensively 
diseased,  or  there  is  a  very  firm  stricture  of  the  nasal  duct,  it  laay  be 
necessary  to  obliterate  the  sac  after  the  removal  of  the  polypus. 

Cases  of  haemorrhage  into  the  sac,  producing  thus  an  imperme- 
ability of  the  latter,  are  of  rare  occurrence.  Two  instances  of  this 
kind  have  been  recorded  by  Von  Graefef.  The  presence  of  chalky 
concretions  (dacryohths)  in  the  ducts  or  in  the  lachrymal  sac  is  also  but 
rarely  observed. 

Whilst  in  some  instances,  there  is  an  absence  of  the  punctum  in 
either  lid,  which  is  generally  due  to  its  obliteration  by  inflammation, 
it  may  also  occur  that  there  is  more  than  one  punctum.  These  sup- 
plementary puncta  are  generally  met  with  in  the  lower  lid,  and  are 
situated  quite  close  to  the  punctum  proper  J. 

*  Vide  a  case  of  Von  Graefe's,  "A.  f.  O.,"  i,  283. 

t  "  A.  f.  0.,"  iii,  1,  337. 

J  Vide  cases  of  Supplementary  Puncta  recorded  amongst  others  by  V.  Grraefe, 
"A.  f.  O.,"  i,  1,  288;  Weber,  ib.,  viii,  i,  1,  352;  and  Zeliender,  "Klin.  Mouatsbl.," 
1863,  p.  394. 


Chapter  XVI. 
DISEASES    OF   THE    OEBIT. 


1.— INFLAMMATION  OF  THE    CELLULAR  TISSUE  OF  THE 
ORBIT  (CELLULITIS  ORBITS). 

The  symptoms  and  course  of  this  disease  are  generally  of  a  very  acute 
and  severe  inflammatory  character.  The  eyelids  become  rapidly 
swollen,  red,  and  hot,  the  palpebral  and  ocular  conjunctiva  much 
injected,  and  there  is  mostly  great  serous  chemosis,  surrounding  the 
cornea  in  the  form  of  a  thick  dusky-red  mound,  the  edges  of  which 
may  even  overlap  and  partially  hide  the  cornea.  The  patient  com- 
plains of  intense,  intermittent  pain  in  and  around  the  eye,  and  extend- 
ing over  the  corresponding  side  of  the  forehead.  There  is  also  generally 
marked,  febrile  constitutional  disturbance ;  and  if  the  inflammation 
should  extend  from  the  orbit  to  the  cranium,  severe  cerebral  symptoms 
will  supervene.  The  eyeball  soon  becomes  protruded.  At  the  outset 
of  the  disease,  this  protrusion  is  not  very  marked,  and  may  only  become 
evident  when  the  two  eyes  are  compared.  But  when  the  inflammatory 
swelling  of  the  orbital  cellular  tissue  increases,  and  still  more  when  pus 
is  formed,  the  exophthalmos  rapidly  augments,  perhaps  even  to  such 
a  degree,  that  the  dusky,  swollen  lids  can  no  longer  be  closed  over  the 
eyeball,  but  the  latter  projects  more  or  less  between  them.  If  the  pus 
collects  chiefly  at  the  bottom  of  the  orbit,  the  protrusion  is  uniform, 
and  straightforward  in  the  axis  of  the  eyeball,  and  not  in  one  par- 
ticular direction,  as  is  generally  the  case  in  the  exophthalmos  accom- 
panying periostitis  of  the  orbit.  The  movements  of  the  eyeball  are 
also  uniformly  impaired,  and  not  especially  so  in  one  direction.  If  the 
patient  attempts  to  move  the  eye,  or  it  is  touched,  more  especially  if  it 
is  slightly  pushed  back  into  the  orbit,  intense  pain  is  produced.  But 
this  is  not  the  case  if  the  point  of  the  little  finger  be  gently  passed 
along  and  somewhat  beneath  the  edge  of  the  orbit,  and  we  do  not  find 
a  special  poLut,  where  its  touch  excites  great  pain,  as  is  the  case  in 
periostitis.  The  formation  of  pus  is  generally  accompanied  by  well- 
marked  rigors. 

2  s  2 


628  DISEASES   OF   THE   ORBIT. 

From  the  exposui'e  of  the  protruded  eyeball  to  the  atmosphere,  the 
secretions  on  the  surface  of  the  conjunctiva  and  the  chemotic  swelling 
become  dried  in  the  form  of  hard,  dark  crusts.  The  surface  of  the 
cornea  may  also  become  roughened  and  clouded,  from  desiccation  of  its 
epithelium  and  its  exposm-e  to  mechanical  irritants.  The  sight  is  often 
much  impaired  by  the  stretching  of,  or  pressure  exerted  upon,  the  optic 
nerve,  and  the  retinal  veins  are  generally  more  or  less  engorged  and 
tortuous ;  there  being,  perhaps,  at  the  same  time  a  serous  infiltration  of 
the  disc  and  the  retina  in  its  vicinity.  The  field  of  vision  is  also  some- 
v^hat  contracted,  often  considerably  so.  If  the  exophthalmos  lasts  for 
any  length  of  time,  optic  neuritis  may  supervene  upon  the  congestion 
and  engorgement  of  the  optic  nerve,  followed,  perhaps,  by  consecutive 
atrophy  of  the  latter. 

If  the  pus  be  formed  in  suflB.cient  quantity,  it  makes  its  way  forward 
from  the  bottom  of  the  orbit,  and  may  cause  distinct  fluctuation  behind 
the  conjunctiva  or  the  lids  ;  and  it  perforates  either  through  the  lid  or 
through  the  conjunctiva,  and  in  the  latter  case,  it  will  appear  to  come 
from  within  the  eye.  But  the  inflammation  and  suppuration  may  also 
invade  the  eyeball,  and  panophthalmitis  be  set  up  ;  pus  will  appear  in 
the  anterior  chamber,  the  pain  will  be  still  more  increased  in  severity, 
and  will  only  be  ameliorated  when  the  cornea  gives  way,  and  the 
lens  and  the  humours  of  the  eye  are  evacuated.  Sometimes,  the  swel- 
ling of  the  eyelids  is  so  tense  and  great,  that  all  sense  of  fluctuation 
is  lost. 

Although  the  severity  of  the  inflammatory  symptoms  met  with  in 
orbital  cellulitis  vary  considerably  in  degree,  the  disease  generally  runs 
a  more  or  less  acute  course.  But  according  to  Mackenzie,*  the  latter 
may,  in  very  rare  instances,  be  extremely  chronic.  I^ot  until  a  very 
long  time,  perhaps  many  months,  has  elapsed,  does  matter  accumulate 
in  the  orbit,  and  then  the  eye  gradually  protrudes,  the  lids  become 
somewhat  swollen  and  red,  the  pus  makes  its  way  to  the  surface,  the 
skin  gives  way,  and  a  sinus  may  be  left,  often  proving  extremely 
obstinate  in  the  treatment. 

In  framing  our  prognosis,  we  must  always  remember  that  cellulitis 
not  unfrequently  becomes  complicated  with  periostitis,  leading  sub- 
sequently to  caries  or  necrosis.  That,  moreover,  the  inflammation  may 
extend  backwards  along  the  periosteum  to  the  membranes  of  the  brain, 
producing  meningitis  or  abscess  of  the  brain.  If  caries  or  necrosis  of 
the  walls  of  the  orbit  has  taken  place,  the  pus  may  make  its  way 
through  this  aperture  into  the  cranium  or  antrum  of  Highmore,  etc. 
Moreover,  the  patient's  general  health,  already  perhaps  undermined  by 
a  long  and  very  serious  illness,  may  give  way  beneath  the  acute  and. 
protracted  sufierings  produced  by  the  disease,  if  the  latter  is  improperly 
*  Diseases  of  the  Eje,  299. 


INFLAMMATION  OF  THE  CELLULAR  TISSUE  OF  THE  ORBIT.      629 

allowed  to  rtin  its  course,  and  is  Bot  arrested  and  relieved  by  a  timely 
evacuation  of  the  pus. 

Amongst  the  most  frequent  causes  of  inflammation  of  the  cellular 
tissue  of  the  orbit,  are  contused  or  incised  wounds  of,  and  the  lodge- 
ment of  foreign  bodies  in,  the  orbit.  The  disease  may  also  be  caused 
by  sudden  changes  of  temperature,  and  exposure  to  cold  and  wet ;  and 
it  may  occur  secondarily  in  severe  constitutional  diseases,  such  as 
pyaemia,  puerperal  fever,  etc.  It  may  also  be  due  to  the  extension  of 
the  inflammation  from  neighbouring  parts,  as  in  erysipelas  of  the  head 
and  face,  severe  inflammation  of  the  lachrymal  sac,  or  operations  per- 
formed upon  the  latter,  more  especially  its  destruction  by  the  galvano- 
caustic  apparatus  or  very  strong  caustics  ;  or  it  may  ensue  upon  panoph- 
thalmitis, or  operations  upon  the  eye  or  eyelids. 

The  treatment  should  be  chiefly  directed  to  subduing  and  arresting 
the  inflammatory  symptoms.     If  the   disease  is  due  to  an  injury,  the 
treatment  suitable  to  its  special  character  (vide  Injuries  of  the  Orbit) 
must  be  adopted,  and  cold  compresses  and  leeches  should  be  applied. 
But  if  suppuration  has  already  set  in,  these  applications  should  be 
changed  for  hot  poppy  fomentations  or  hot  poultices,  and  a  free  incision 
with  a  bistoury  should  be  made  at  an  early  period,  in  order  that  the 
pus  may  be  evacuated.     If  much  doubt  exists  as  to  the  true  nature  of 
the  disease,  a  small  exploratory  incision  should  be  made,  and  if  pus  is 
found  to  ooze  out,  the  incision  should  be  sufficiently  enlarged  to  permit 
of  its  free  and  ready  escape.     If  possible,  the  opening  should  be  made 
through  the  conjunctiva,  and  not  through  the  eyelids  ;  but  if  the  abscess 
points  directly  beneath  the  latter,  the  incision  must  be  made  at  this  spot. 
In  making  the  incision  through   the    conjunctiva,    the  upper   lid 
should  be  raised  with  the  finger,  and  a  scalpel,  or  the  point  of  a  cataract 
knife,  passed  through  the  conjunctiva  above  the  upper  edge  of  the  eye- 
ball into  the  orbit.      Care  should  be  taken  that  the  globe  is  not  injured, 
and  to  avoid  this,  the  edge  of  the  knife  should  be  directed  somewhat 
upwards.     Warm  poultices  are  then  to  be  applied,  and  the  edges  of  the 
wound  are  to  be  kept  open  by  daily  passing  a  probe  between  them.     If 
the  track  of  the  wound  is  deep  and  long,  and  a  fear  is  entertained  that 
it  may  not  heal  fi-om  the  bottom,  a  small  dossil  of  lint  should  be  inserted 
as  a  tent,  and  changed  every  day.     The  sinus  should  also  be  syringed 
out  once  or  twice  a  day  with  a  mild  astringent  lotion  (Zinc.  Sulph.  gr. 
iv.  Aq.  dist.  3ij).      If  the  healing  of  the  sinus  prove  obstinate  and  pro- 
tracted, a  careful  examination  must  be  made  as  to  the  presence  of 
carious   or  necrosed  portions  of  bone.     In  the  latter  case,  time  should 
be  allowed  for  the  loosening  or  detachment  of  the  spicula  of  bone,  and 
the  incision  should  then  be  sufficiently  enlarged,  and  the  fragments  of 
bone  removed  with  a  pair  of  forceps. 

If  panophthalmitis  co-exists  with  the  abscess  in  the  orbit,  and  there 


630  DISEASES   OF   THE   ORBIT. 

is  pus  in  tte  anterior  cliamber,  paracentesis  should  be  performed,  and 
the  pus  evacuated. 

The  patient's  health  should  be  sustained  by  a  generous  diet  and  tonics, 
care  being  at  the  same  time  taken  that  the  bowels  are  kept  well  open, 
and  febrile  symptoms  alleviated  by  maintaining  a  free  action  of  the 
kidneys  and  the  skin. 

When  the  pus  has  been  evacuated,  the  protrusion  of  the  eye  will 
gradually  diminish,  and  the  latter  re-assume  its  normal  position.  If 
the  eye  has  otherwise  escaped  all  injury,  and  the  impairment  of  vision 
was  simply  due  to  stretching  of  the  optic  nerve  and  stasis  in  the  retinal 
circulation,  the  sight  will  rapidly  improve.  Sometimes,  however,  a 
curtailment  of  the  movements  of  the  eye  in  certain  directions  may 
remain  behind. 

2.— PERIOSTITIS  OF  THE  ORBIT. 

We  meet  with  two  forms  of  periostitis  of  the  orbit,  the  acute  and 
the  chronic. 

In  the  acute  periostitis,  the  inflammatory  symptoms  are  often  very 
severe  and  pronounced.  The  patient  complains  of  great  pain  in  and 
around  the  eye,  and  the  constitutional  symptoms  may  also  be  very 
severe.  The  eyelids,  more  especially  the  upper  one,  become  swollen, 
red,  hot,  and  painful,  but  the  swelling  and  redness  are,  as  a  rule,  not  so 
extreme,  and  do  not  advance  with  such  rapidity,  as  in  cellulitis  of  the 
orbit ;  moreover,  in  periostitis,  the  swelling  of  the  two  Hds  is  not  alike 
in  degree,  but  one  is  generally  more  swollen  than  the  other.  The  ocular 
conjunctiva  and  sub-conjunctival  tissue  are  injected,  and  there  is  more 
or  less  serous  chemosis.  The  eyeball  becomes  somewhat  protruded, 
even  perhaps  to  such  a  degree  (if  much  pus  is  formed)  that  the  eye- 
lids cannot  be  closed.  The  protrusion  is  not,  however,  straightforward, 
as  is  generally  the  case  in  abscess  of  the  orbit,  but  towards  one  side, 
the  movements  of  the  eyeball  are  therefore  not  curtailed  equally  in  aU 
directions,  but  more  in  certain  directions  than  in  others.  This  is  due 
to  the  fact  that  the  periostitis  is  chiefly  and  specially  confined  to  one 
wall  or  one  portion  of  the  orbit.  Thus,  if  the  inuer  and  upper  wall  of 
the  orbit  are  affected,  the  eyeball  would  protrude  downwards  and  out- 
wards, and  the  movements  would  be  especially  curtailed  in  the  upward 
and  inward  direction.  If  the  tip  of  the  little  finger  is  passed  along  the 
upper  or  lower  edge  of  the  orbit,  and  pushed  somewhat  back  into  the 
cavity,  we  are  often  able  to  detect  a  point  where  its  pressure  causes 
severe  pain,  and  where  there  is  distinct  swelling,  thus  indicating  the 
seat  of  the  disease.  Sometimes,  the  patients  can  themselves  localize 
the  situation  of  the  periostitis  with  much  exactitude.  In  the  course  of 
acute  periostitis,  the  cellular  tissue  generally  also  becomes  extensively 


PERIOSTITIS  OF   THE   ORBIT.  631 

inflamed,  a  great  amount  of  pus  may  be  formed,  the  eye  be  very 
considerably  protruded,  and  its  movements  greatly,  or  even  completely, 
impaired.  The  disease  then  assumes  a  mixed  type  of  periostitis  and 
abscess  of  the  orbit.  The  periostitis  is  generally  accompanied  from 
the  outset  by  a  certain  degree  of  inflammation  of  the  bone  itself. 

In  the  chronic  periostitis,  the  inflamraatory  symptoms  are  far  less 
pronounced,  and  the  disease  is  more  protracted  and  insidious  in  its 
course.  The  swelling  and  redness  of  the  eyelids,  the  injection  of  the 
conjunctiva,  the  chemosis,  and  the  protrusion  of  the  eye,  are  generally 
far  less  severe  than  in  the  acute  form.  Pain  is  experienced  in  and 
above  the  eye,  which  mostly  increases  in  severity  towards  night,  and  is 
markedly  augmented  by  pressure  upon  the  edge  of  the  orbit,  or  by 
pressing  the  eye  backwards  in  a  certain  direction.  Sometimes,  decided 
swelling  of  the  orbit  can  be  detected  at  one  point.  A  certain  amount 
of  suppuration  generally  takes  place,  and  if  pus  is  formed  in  consider- 
able q^^antity,  it  will,  of  course,  cause  great  protrusion  of  the  eye. 
As  a  rule,  however,  the  suppui-ation  is  limited,  and  the  pus  is  apt  to 
accumulate  between  the  periosteum  and  the  bone,  and  lift  up  the  former. 
The  periosteum  often  becomes  greatly  swollen  and  thickened,  giving 
rise  perhaps  to  little  nodules  or  tuberosities.  These  may  subsequently 
again  diminish  in  size,  and  finally  only  leave  a  somewhat  tliickened 
condition  of  the  periosteum,  or  they  may  undergo  ossification,  and  thus 
give  rise  to  exostoses.  If  the  bone  becomes  involved,  caries,  and  often 
necrosis  will  result,  and  the  inflammation  or  the  pus  may  extend 
through  the  aperture  in  the  orbit  to  the  cavity  of  the  cranium,  or 
into  the  frontal  sinus.  Indeed,  the  great  danger  of  the  disease  is,  that 
the  inflammation  should  extend  from  the  orbit  back  to  the  membranes 
of  the  brain,  and  set  up  fatal  meningitis,  or  that  an  abscess  should  be 
formed  in  the  brain. 

Periostitis  is  sometimes  met  with  in  infants,  and  is  indeed  far  more 
common  amongst  young  persons  than  in  adults.  The  most  frequent 
causes  of  acute  periostitis  are  penetrating  wounds  of  the  orbit  with 
sharp  cutting  instruments  ;  or  severe  contusion  of  its  edge  from  blows, 
or  blunt  instruments  ;  and  the  lodgement  of  foreign  bodies  within  the 
orbit.  It  may  also  be  secondary,  the  inflammation  extending  from  the 
periosteum  of  some  of  the  neighbouring  cavities,  e.g.,  frontal  sinus, 
maxillary  space,  etc.  Exposure  to  damp  and  cold  and  to  sudden  changes 
of  temperature  may  also  give  rise  to  it.  As  already  stated,  it  may 
likewise  appear  in  the  course  of  inflammation  of  the  cellular  tissue  of 
the  orbit.      Chronic  periostitis  is  most  frequently  due  to  syphilis. 

The  general  plan  of  treatment  resembles  very  closely  that  recom- 
mended for  inflammation  of  the  cellular  tissue  of  the  orbit,  and 
if  the  presence  of  pus  is  suspected,  it  should  be  evacuated  as  early  as 
possible.     Where  the  disease  is  due  to  syphilis,  the  iodide  and  bromide 


632  DISEASES  OF  THE  ORBIT. 

of  potassium,  in  combination  with  some  preparation  of  mercury,  should 
be  administered,  or  the  mercurial  bath  should  be  employed.  Care  should 
be  taken  not  to  enfeeble  the  patient's  health,  but  to  fortify  it  as  much 
as  possible  by  tonics  and  a  generous  diet. 


3.— CARIES  AND  NECROSIS  OF  THE  ORBIT. 

At  the  commencement  of  a  carious  affection  of  the  bones  of  the 
orbit,  there  is  generally  a  certain  degree  of  csdematous  swelling  of  the 
eyelids,  which  are  also  somewhat  red  and  perhaps  painful.  The  con- 
junctiva and  subconjunctival  tissue  are  injected,  and  the  eye  is  irritable 
and  watery.  The  oedema  of  the  eyelids  is  often  very  considerable,  par- 
ticularly in  children  of  a  scrofulous  diathesis.  Soon,  a  spot  is  noticed 
where  the  eyelid  assumes  a  more  dusky  red  tint ;  here  the  abscess 
points,  the  skin  gives  way,  and  through  this  small  perforation  a  thin 
scanty,  muco-purulent  or  "  stringy  "  discharge  oozes  out.  On  passing 
a  probe  through  this  aperture,  we  find  that  it  leads  to  a  portion  of  bare 
roughened  bone.  The  edges  of  the  opening  generally  become  somewhat 
everted,  swollen,  and  ulcerated,  and  covered  perhaps  with  fleshy  gi'anu- 
lations.  A  portion  of  the  bone,  as  a  rule,  becomes  necrosed,  and  small 
fragments  are  exfoliated.  After  this  condition  has  lasted  for  a  more  or 
less  considerable  length  of  time,  the  sinus  closes  up,  the  aperture  heals, 
but  during  the  process  of  cicatrization,  the  integuments  become 
adherent  to  the  periosteum,  and  thus  an  eversion  of  the  lid,  perhaps  of 
very  considerable  extent,  may  be  produced,  causing  a  great  exposure  of 
the  eyeball  (lagophthalmos)  with  all  its  deleterious  consequences. 

The  course  of  the  disease  is  often  most  protracted,  especially  in  per- 
sons of  feeble  health,  and  of  a  scrofulous  or  syphilitic  diathesis,  in  whom 
relapses  are  very  apt  to  occur.  The  disease  improves,  the  sinus  and 
external  aperture  appear  to  be  healing  kindly,  when  a  relapse  takes 
place,  fresh  symptoms  of  inflammation  supervene,  the  discharge  again 
increases  in  quantity,  and  fresh  portions  of  bone  are  perhaps  exfo- 
liated. 

Caries  and  necrosis  may  occur  in  different  portions  of  the  orbit ; 
thus,  the  bottom  of  the  latter  may  be  the  seat  of  the  disease,  as  is 
often  the  case  after  periostitis  of  this  portion  of  the  cavity.  In  rarer 
instances,  it  may  supervene  upon  inflammation  of  the  cellular  tissue  of 
the  orbit,  accompanied  by  periostitis.  Sometimes  the  caries  is  confined 
to  the  margin  of  the  orbit,  or  it  occurs  just  within  the  cavity  near  the 
edge.  In  such  cases,  the  upper  or  lower  lid,  according  to  circum- 
stances, may  become  extensively  involved  in  the  cicatrix,  and  a  very 
considerable  ectropium  result.  These  cases  of  caries  and  necrosis  of  the 
margin  of  the  orbit  ai-c  generally  the  result  of  a  blow  or  fall  upon  this 


INFLAMMATION   OF   THE   CAPSULE   OF   TENON.  633 

part,  and  are  frequently  met  with  in  children,  more  particiilarly  those 
of  a  scrofulous  diathesis.  Syphilis  is  a  frequent  cause  of  caries  of  the 
orbit,  and  the  disease  of  the  bone  may  in  such  cases  be  due  to  an 
extension  of  the  affection  from  the  nasal  fossae. 

The  principles  of  treatment  should  resemble  those  recommended  for 
periostitis.  The  pus  should  be  evacuated  as  early  as  possible,  the 
fistulous  sinus  be  washed  out  frequently  with  warm  water  or  mild 
astring'cnt  injections,  and  a  small  tent  of  lint  should  be  introduced,  in 
order  to  cause  the  sinus  to  heal  from  the  bottom.  If  a  loose  spiculum 
of  bone  is  detached  with  the  probe,  the  external  opening  should  be 
somewhat  enlarged,  and  the  fragment  be  carefully  removed  with 
forceps.  The  treatment  of  the  lagophthalmos  and  ectropium  consequent 
upon  the  caries,  is  fully  desci-ibed  in  the  articles  upon  these  subjects. 

4.— INFLAMMATION  OF  THE  CAPSULE  OF  TENON. 

The  fibrous  capsule  which  envelopes  the  eyeball  (capsule  of  Tenon) 
is  occasionally  subject  to  inflammation.  This  disease  is  particularly 
distinguished  by  the  api)earance  of  a  more  or  less  marked  chemosis 
round  the  cornea,  there  being  at  the  same  time  considerable  conjunc- 
tival and  subconjunctival  injection.  On  closer  examination,  we  find  that 
there  is  no  apparent  cause  for  this  chemosis,  for  the  cornea,  iris,  and 
deeper  tunics  of  the  eye  are  unaflPected,  and  the  sight  and  the  field  of 
vision  are  also  good.  The  eyehds  are  Hkewise  somewhat  red  and 
swollen.  The  eyeball  is,  moreover,  slightly  protruded,  although  per- 
haps to  so  inconsiderable  a  degree  that  it  might  escape  observation 
unless  the  state  of  the  two  eyes  is  compared.  There  is,  at  the  same 
time,  a  certain  impairment  of  the  movements  of  the  eyeball,  which  is 
especially  evident  in  the  extreme  movements  in  difierent  directions, 
when  diplopia  will  also  ainse.  The  pain  in  and  around  the  eye  may  be 
somewhat  severe,  but  it  never  reaches  the  same  intensity  as  in  cellu- 
litis or  periostitis  of  the  orbit.  The  progress  of  the  disease  is  generally 
slow,  eight  or  ten  weeks  perhaps  elapsing  before  it  is  cured. 

It  is  generally  of  rheumatic  origin,  being  due  to  a  draught  of  cold 
air,  as,  for  instance,  in  railway  travelling,  etc.,  or  to  sudden  changes  of 
temperature.  It  is  also  seen  in  cases  of  irido-choroiditis  supervening 
upon  operations,  egpecially  those  for  cataract.  According  to  Wecker, 
it  may  also  follow  the  operation  for  strabismus,  if  the  sclerotic  has  been 
much  exposed,  or  the  capsule  of  Tenon  too  freely  incised. 

If  the  inflammatory  symptoms  are  severe,  a  few  leeches  should  be 
applied  to  the  temple,  and  warm  poppy  fomentations  be  prescribed, 
together  with  the  compound  belladonna  ointment.  If  the  Tenonitis  is 
due  to  a  traumatic  origin,  as,  for  instance,  ia  the  operation  for  strabis- 
mus, ice  compresses  should  be  applied. 


634  DISEASES   OF   THE   ORBIT. 

5.— EXOPHTHALMIC    GOITRE    (GRAVES'S    DISEASE, 
MORBUS  BASEDOWII,  ETC.). 

This  is  a  very  interesting*  and  peculiar  disease,  tlie  true  nature  and 
cause  of  which  are  at  present  unknown.  Amongst  the  first  symptoms 
are,  generally,  great  palpitation  and  acceleration  of  the  action  of  the 
heart,  the  pulse  perhaps  reaching  120  or  150  beats  in  the  minute. 
There  is  at  the  same  time  much  nervous  excitement  and  dyspnoea. 
Sometimes  there  are,  moreover,  symptoms  of  gastric  derangement, 
such  as  frequent  and  obstinate  retching  and  vomiting,  or  diarrhoea. 
It  is  now  perhaps  also  noticed  that  the  eyes  have  a  pecuHar  and 
somewhat  staring  look,  which  is  due  to  a  retraction  of  the  upper 
eyelid,  leaving  the  eyeball  much  uncovered,  and  giving  an  expres- 
sion of  astonishment  to  the  patient.  Moreover,  as  Von  Graefe  has 
pointed  out,  the  upper  lid  does  not  quite  follow  the  movements  of  the 
eveball  when  the  person  looks  upwards  or  downwards,  but  remains 
somewhat  too  elevated.  This  elevation  of  the  upper  lid  is  quite 
independent  of  the  exophthalmos,  and  generally  appears  during  the 
stage  of  progression,  and  may  disappear  without  any  diminution  in  the 
protrusion  of  the  eye.  It  may  also,  according  to  Von  Graefe,  be 
relieved  by  the  use  of  subcutaneous  injection  of  morphia.  The 
cardiac  symptoms  may  have  lasted  perhaps  some  little  time  before 
those  of  bronchocele  and  exophthalmos  present  themselves.  The  latter 
symptoms  generally  appear  about  the  same  time,  but  do  not  necessarily 
bear  any  absolute  relation  to  each  other,  and  need  not  co- exist ;  for, 
according  to  Prael,*  in  exceptional  instances,  the  bronchocele  may 
be  absent.  There  is,  moreover,  nothing  peculiar  in  this  form  of  bron- 
chocele, excepting  that  the  veins  are  generally  much  dilated,  even,  per- 
haps to  such  a  degree  that  the  disease  might  be  termed  "bronchocele 
aneurysmatica ;"  and  often  a  distinct  diastolic  murmur  can  be  heard  in 
them.  According  to  Virchow,t  there  is,  at  the  commencement,  only  a 
simple  swelling  of  the  thyroid  gland,  the  disease  becoming  gradually 
developed  into  a  true  bronchocele.  Degenerative  changes,  of  a  gelati- 
nous or  cystoid  nature  may  then  occur,  or  nodulated,  fibroid  indurations 
be  formed.  As  all  these  changes  occur  also  in  common  bronchocele, 
Vii'chow  thinks  it  probable  that  the  affection  of  the  thyroid  is  of  a 
secondary  nature. 

At  the  commencement,  the  cardiac  affection  seems  simply  to  con- 
sist in  the  greatly  increased  action  and  violent  palpitations  of  the  heart, 
but  after  a  time  dilatation  and  hypertrophy,  more  especially  of  the  left 
ventricle,  ensue.     There  is  often  a  marked  bellows  mm^mur,  without 

*  "  A.  f.  0.,"  iii,  2,  209. 

t  "Krankhaftc  Guscliwulste,"  iii,  1,  76. 


EXOPHTHALMIC   GOITRE.  635 

perhaps  any  valvular  affection,  and  the  murmiir  may  extend  into  the 
aorta  and  carotid.  The  pulsation  in  the  carotid  is  sometimes  quite 
evident  at  a  little  distance  from  the  patient.  The  aorta  and  larger 
arteries  have  occasionally  been  found  to  have  undergone  atheromatous 
changes. 

The  exophthalmos  may  become  so  considerable,  that  the  eyelids 
cannot  be  closed  over  the  cornea,  but  the  latter,  and  a  more  or  less  con- 
siderable portion  of  the  sclerotic,  protrude  between  them.  The  protru- 
sion of  the  eye  is  not  generally  straightforward,  in  the  direction  of  the 
optic  axis,  but  towards  one  side,  frequently  the  nasal.  On  account 
of  the  constant  exposure  of  the  uncovered  cornea  to  the  influence  of 
external  irritants,  its  epithelial  covering  becomes  roughened  and  thick, 
tdcers  are  formed,  w^hich,  extending  in  circumference  and  depth,  may 
lead  to  extensive  perforation  of  the  cornea,  and  even  to  subsequent 
atrophy  of  the  eyeball.  The  eyelids  at  the  same  time  become  inflamed, 
the  ocular  conjunctiva  injected,  and  perhaps  oedematous,  and  of  a  dusky- 
red  colour  from  constant  exposure  to  the  atmosphere  and  irritants. 
The  suppuration  which  may  occur  in  this  disease  is  not,  however,  of 
nearo-paralytic  origin,  but  Von  Graefe  thinks  it  is  due  to  a  paralysis 
of  the  "  trophic  "  Ghres  of  the  fifth  nerve,  as  was  shown  in  Meissner's 
experiments. 

Cases  of  suppuration  of  the  cornea  are  not,  however,  of  frequent 
occurrence,  and  I  bave  only  met  with  a  single  instance  of  the  kind, 
where  a  young  woman  affected  with  exophthalmic  goitre,  had  lost  both, 
eyes  from  suppuration  of  the  cornea,  and  the  eyeballs,  although 
shrunken,  were  still  very  prominent.  According  to  Von  Graefe,  it 
occurs  more  frequently  amongst  men  than  women  ;  thus  out  of  14  cases 
in  which  suppuration  took  place,  it  occurred  ten  times  in  men  and  four 
times  in  women.* 

The  exophthalmos  is  due  to  hypertrophy  of  the  adipose  cellular 
tissue  of  the  orbit,  and  to  a  hyperasmic  swelling  of  this  tissue,  which, 
may  at  first  be  diminished  by  pressure  and  rapidly  disappears  after 
death. t  Recklinghausen  has  also  observed  fatty  degeneration  of  the 
muscles  of  the  eyeball.  Dr.  WrightJ  found,  besides  strong  dilatation 
of  the  veins,  a  small  quantity  of  half  coagulated  blood  extravasated 
over  the  eyeball. 

The  true  cause  of  the  disease  and  the  nature  of  the  connection 
between  the  affection  of  the  heart,  the  th}Toid  gland,  and  the  eye  are 
at  present  unknowTi.  It  was  supposed  by  some  authors,  that  the 
pressure  of  the  enlarged  thyroid  upon  the  cervical  blood-vessels  caused 
the  protrusion  of  the  eye.  In  opposition  to  this  view  it  may,  however, 
be  urged  that  we  often  meet  with  very  large  bronchoceles  without  any 

*  Berliner,  "  Klin.  Wochensclir.,"  1867,  649.  f  Yirchow,  1.  c,  76. 

X  "  Med.  Times  and  Gazette,"  1865,  Nov. 


636  DISEASES   OF   THE   ORBIT. 

exophtlialmos ;  and,  on  the  other  hand,  as  has  been  shown  by  Praell, 
the  latter  may  exist  without  any  enlargement  of  the  thyroid  gland. 
Others  have  supposed  that  the  symptoms  are  due  to  anaemia,  and 
Mackenzie  speaks  of  the  disease  as  "  Anaemic  Exophthalmos."  But  it 
is  impossible  that  ansemia  could  be  the  direct  cause  of  such  a  condition, 
and  it  could,  therefore,  as  Virchow  points  out,  only  act  in  so  far,  that 
the  morbid  condition  of  the  blood  exerts  a  deleterious  influence  upon 
the  nerves. 

It  is,  however,  far  more  probable  that  the  affection  is  due  to  an 
irritation  or  neurosis  of  the  sympathetic  nerve,  producing  hypertrophy 
of  the  adipose  tissue  of  the  orbit  and  dilatation  of  the  veins.  There 
is,  moreover,  another  fact  which  would  argue  in  favour  of  this  view 
of  irritation  of  the  sympathetic,  viz.,  the  retraction  of  the  upper  lid ; 
for  H.  Miiller  discovered  unstriped  muscular  fibres  in  the  upper  Kd, 
which  are  supplied  by  branches  of  the  sympathetic.  Any  irritation  of 
these  nervelets  would  cause  an  elevation  of  the  lid,  whereas,  if  this 
irritability  were  allayed,  the  retraction  would  disappear.  Now  the 
latter,  as  has  already  been  mentioned,  may  be  observed  to  occur  after 
the  subcutaneous  injection  of  morphia.  The  anatomical  conditions  of 
the  sympathetic  have,  however,  been  found  to  vary  considerably.  Thus 
some  observers  (Wright,  Moore,  Trousseau,  etc.)  found  the  cervical 
ganglia  of  the  sympathetic  enlarged,  hard,  and  firm  ;  and,  on  microscopi- 
cal examination,  they  were  seen  to  be  filled  with  a  granular  substance, 
like  a  lymphatic  gland  in  the  first  stage  of  tuberculosis.  The  trunk  of 
the  sympathetic,  as  well  as  the  branches  going  to  the  inferior  thyroid 
and  vertebral  arteries,  were  found  to  be  enlarged.  Whereas  Reckling- 
hausen,* on  the  contrary,  observed  that  the  trunk  and  the  ganglia  of 
the  sympathetic  were  diminished '  in  size,  as  if  atrophic,  without,  how- 
ever, presenting  any  histological  changes.  One  fact,  which  argues 
rather  against  the  assumption  that  the  disease  is  due  to  irritation  of  the 
sympathetic,  is  the  condition  of  the  pupil ;  for  the  latter  was  only  in 
some  cases  dilated. 

Virchow,  in  speaking  of  the  functional  disturbances,  also  calls 
attention  to  the  fact,  that  together  with  the  disappearance  of  the  bron- 
chocele  in  consequence  of  small  doses  of  iodine,  marked  acceleration  of 
the  pulse,  and  palpitation  of  the  heart  may  be  observed,  l^ow  as  the 
same  thing  has  been  occasionally  noticed  when  spontaneous  diminution 
of  the  bronchocele  has  taken  place,  the  question  arises  whether  these 
symptoms  may  not  be  due  to  an  admixture  of  soluble  goitre-material 
with  the  blood. 

The  disease  occurs  most  frequently  in  women,  especially  during  the 
time    of  puberty,   or  during   confinement.     It  is    also    observed  to  be 
paired  with  disturbances    of  the  uterine  functions,  particulaily  chlo- 
*  Virchow,  1.  cit.,  p.  80. 


EXOPHTH^VLMIC   GOITRE.  637 

rosis,  and  may  supervene  upon  severe  constitutional  diseases.  Accord- 
ing to  Von  Graefe,  it  is  not  only  more  rare  amongst  men,  but  in  them 
it  occurs  at  a  later  period  and  with  greater  severity.  It  has  been  caused 
by  severe  bodily  labour,  or  mental  shocks,  fright,  great  depression,  etc. 
The  course  of  the  disease  is  mostly  very  slow  and  protracted,  and 
relapses  are  very  apt  to  occur,  more  especially  if  there  still  exists  great 
disturbance  in  the  action  of  the  heart.  Amongst  men,  the  prognosis 
should  be  very  guarded,  as  the  disease  assumes  a  much  more  severe 
character,  and  is  more  frequently  complicated  with  serious  affections  of 
the  cornea.  On  account  of  the  impediment  produced  in  the  intra- 
ocular circulation  by  the  exophthalmos,  the  retinal  veins  are  sometimes 
dilated  and  tortuous,  but  otherwise  there  are  no  changes  in  the  fundus, 
and  the  function  of  the  retina  is  generally  unimpaired.  Hypermetropia 
may  arise  on  account  of  the  flattening  of  the  eye. 

With  regard  to  treatment,  the  most  benefit  seems  to  be  derived 
from  the  administration  of  tonics,  more  especially  the  preparations  of 
quinine  and  steel,  together  with  a  generous  diet,  plenty  of  open-air 
exercise,  and,  if  necessary,  a  change  of  air  and  a  prolonged  residence 
in  the  country.  A  firm  compress  bandage  will  often  cause  the  exoph- 
thalmos to  diminish  considerably.  The  peculiar  retraction  of  the 
upper  eyelid  may  be,  if  necessary,  alleviated  by  an  operation  upon  the 
levator  palpebras,  as  has  be'en  advised  by  Yon  Graefe.  He  was 
formerly  in  the  habit  of  recommending  tarsoraphia  for  this  elevation  of 
the  upper  lid,  but  now  prefers  a  partial  tenotomy  of  the  levator  pal- 
pebrae  superioris.  The  latter  operation  is  to  be  performed  as  follows  :* 
The  horn  spatula  having  been  introduced  beneath  the  upper  lid,  so 
as  to  put  it  well  on  the  stretch,  he  makes  a  horizontal  incision  through 
the  skin  of  the  upper  lid,  extending  nearly  the  whole  length  of  the 
latter,  and  situated  about  1'"  above  the  upper  edge  of  the  tarsal  car- 
tilage. He  then  divides  the  orbicularis,  or,  still  better,  excises  a  small 
horizontal  portion  of  it,  in  order  to  gain  a  better  view  of  the  subjacent 
parts.  A  careful  exposui'e  of  the  tarso-orbital  fascia  Avill  bring  into 
view  the  vertical  or  oblique  striation  which  indicates  the  tendon  of 
the  levator  palpebrse,  which  here  passes  over  into,  and  becomes  blended 
with,  the  cartilage.  With  a  very  nai-row  knife,  the  point  where  they 
are  blended  is  then  to  be  incised  at  each  side,  so  that  only  a  narrow 
central  bridge  (of  about  1'"  in  width)  remains  standing.  Care  must  of 
course  be  taken  not  to  perforate  the  conjunctiva.  The  result  of  the 
operation  is  an  incomplete  ptosis,  which  diminishes  considerably  during 
the  first  few  weeks,  the  remainder  just  neutralizing  the  retraction  of 
the  upper  lid  which  before  existed. 

*  Vide  Compte-Eendu  of  the   Cougres   d'Ophtlialmologie,    1867  ;    also   "Kl. 
MonatsbL,"  1867,  p.  272. 


638  DISEASES   OF   THE   ORBIT. 

6.— TUMOURS  OF  THE  ORBIT. 

It  would  be  quite  beyond  the  plan  and  scope  of  this  work,  to  enter 
at  length  into  all  the  varieties  of  tumour  that  may  be  met  with  in  the 
orbit,  as  well  as  the  points  of  difference  in  their  structure,  diagnosis, 
and  mode  of  development ;  I  shall,  therefore,  confine  myself  to  a  broad 
and  practical  division  of  this  subject,  and  shall  endeavour  briefly  to 
give  the  most  characteristic  and  leading  features  presented  by  the 
principal  varieties  of  tumour,  as  well  as  the  different  modes  of  treat- 
ment which  are  more  especially  indicated. 

Tumours  of  the  orbit  may  be  developed  primarily  in  the  latter,  or 
may  commence  within  the  eye  or  one  of  the  neighboui'ing  cavities, 
and,  gradually  increasing  in  size,  finally  make  their  way  into  the  orbit. 
As  long  as  the  tumour  is  confined  within  the  eye,  its  progress  may  be 
slow  and  protracted,  but  when  it  has  once  perforated  the  ocular  tunics, 
its  growth,  being  no  longer  restrained  by  the  firm  sclerotic,  is  often 
very  rapid,  so  that  it  may  within  a  short  time  attain  a  very  consider- 
able size. 

Tumours  may  be  developed  from  any  part  of  the  orbit ;  they  may 
spring  from  the  bottom  of  the  cavity,  from  its  walls,  or  from  its  most 
anterior  part  close  to  the  edge.  As  the  morbid  growth  increases  in 
size,  the  eyeball  will  be  more  and  more  protruded,  and  the  direction  of 
this  protrusion  will  depend  upon  the  principal  situation  of  the  tumour. 
The  exophthalmos  may  finally  become  so  great,  that  the  eyeball  is  quite 
pushed  out  of  the  orbit  upon  the  cheek.  Together  with  the  protrusion, 
the  movements  of  the  globe  will  be  more  or  less  impaired.  The  eyelids 
are  generally  swollen  and  oedematous,  and  the  oedema  may  be  so  great, 
that  it  is  impossible  to  judge  of  the  true  nature  of  the  tumour,  or  it 
may  even  obscure  the  presence  of  the  latter.  If  the  tumour  is  chiefly 
situated  at  the  upper  part  of  the  orbit,  a  certain  degree  of  ptosis  is 
frequently  present.  The  eyelids  are  in  other  cases  greatly  everted,  their 
exposed  conjunctival  surface  being  swollen  and  fleshy  in  appearance. 
There  is  often  also  a  very  considerable  degree  of  chemosis  of  a  dirty, 
dusky-red  tint.  The  sight  may  sufier  from  the  optic  nerve  being 
stretched  or  pressed  upon  by  the  tumour,  or  from  the  impediment  to 
the  intra-ocular  circulation.  The  efilux  from  the  retinal  veins  is 
retarded,  symptoms  of  inflammation  of  the  optic  nerve  may  supervene, 
and  if  the  tumour  be  not  removed,  the  optic  nerve  may  undergo  con- 
secutive atrophy.  But  the  sight  may  also  be  greatly  impaired,  or  even 
lost  from  inflammation  or  extensive  ulceration  of  the  cornea,  dependent 
upon  its  constant  exposure  to  the  action  of  external  irritants,  when 
the  eye  is  much  protruded.  Perforation  or  sloughing  of  the  cornea 
may  ensue,  and  the  contents  of  the  globe  escaping,  the  eye  may 
gradually  undergo  atrophy. 


FIBROUS   TUMOURS.  639 

In  attempting'  tlie  removal  of  any  tumour  of  the  orbit  by  operation, 
we  should  always  take  into  anxious  consideration  its  size,  rate  of  pro- 
gress, suspected  nature,  and  situation ;  as  well  as  the  condition  of  the 
eye,  and  the  general  health  of  the  patient.  If  there  is  still  sight, 
we  should  always  endeavour  to  remove  the  morbid  growth,  if  possible, 
without  sacrificing  the  eye.  But  in  some  cases,  more  especially  of 
malignant  tumoui-s,  it  is  quite  impossible  to  remove  the  whole  of  the 
morbid  growth,  without  the  removal  of  the  eye  ;  and  in  sucb  instances, 
it  is  far  wiser  to  sacrifice  the  latter,'than  to  run  the  risk  of  leaving  por- 
tions of  tumour  behind,  to  prove  the  ready  source  of  a  recurrence  of  the 
disease.  We  should,  if  possible,  remove  the  tumour  through  the  con- 
junctiva, but  if  this  is  not  practicable,  the  incision  raust  be  carried 
through  the  skin  of  the  lids.  The  incision  should  in  such  a  case  be 
always  horizontal,  and  perhaps  slightly  curved,  so  as  to  correspond 
with  the  natural  wi'inkles  of  the  skin,  and  thus  avoid  the  formation  of 
unsightly  cicatrices. 

In  order  to  gain  more  room,  to  work  in,  it  may  also  be  necessary  to 
divide  the  outer  can  thus.  We  should  always  endeavour  to  extii'pate 
the  tumour  without  any  injury  to  the  neighbouring  parts,  and  for  this 
reason  the  knife  must  not  be  two  freely  used,  but  the  attachments  of 
the  tumour  should  rather  be  loosened  with  the  tip  of  the  finger, 
the  handle  of  a  scalpel,  or  with  the  point  of  a  silver  knife.  In  some 
tumours,  it  is  necessary  to  gouge  out  the  different  portions,  or  to  snip 
them  off  the  walls  of  the  periosteum  with  a  pair  of  blunt-pointed,  curved 
scissors.  The  use  of  the  chloride  of  zinc  paste  ha  cases  of  removal  of 
malignant  tumoui'S,  as  well  as  those  whose  recuiTcnce  may  be  feared, 
will  be  considered  when  speaking  of  these  tumouj's  in  detail. 

(1.)  FIBROUS  TUMOURS. 

The  fibrous  tumour  is  especially  characterised  by  the  fact  that  its 
structure  closely  resembles  that  of  the  radiating  fibrillar  connective 
tissue,  the  fibrQlae  being  closely  packed  together.  On  a  section,  such  a 
tumour  presents  a  firm  and  perhaps  somewhat  rough  sm^face,  traversed 
by  bundles  of  parallel  fibres.  Its  colour  is  of  a  greyish- white,  or 
greyish-yellow  tint.  The  tumoiir  is  always  surrounded  by  a  distinct 
sheath  of  thickened  connective  tissue,  and  is  penetrated  by  a  small 
number  of  vessels.  These  tumours  may  undergo  secondary  changes,  and 
cysts  may  be  formed,  and  in  such  a  case  their  firmness  is  diminished, 
and  a  certain  degree  of  fluctuation  may  be  perceptible ;  and  if  this  is 
considerable,  they  may  be  easily  mistaken  for  cysts.  Or  again,  they 
may  undergo  osseous  or  calcareous  changes,  the  bone  being  generally 
met  with  in  the  form  of  small  spicula. 

These  tumours  grow  from  the  periosteum  either  by  a  broad  base,  or 


640  DISEASES   OF   THE   ORBIT. 

by  one  or  more  pedicles.  They  are  generally  formed  near  tlie  edge  of 
the  orbit,  and  if  they  are  stalked,  they  may  be  felt  in  the  form  of 
small,  firm,  circumscribed,  moveable  growths.  The  consistence  of  the 
tnmour  may  vary  very  considerably.  It  is  generally  firm  and  hard, 
from  the  thickening  and  condensation  of  the  radiating,  connective  tissue 
elements.  In  other  cases,  however,  it  is  softish  and  perhaps  lobulated, 
or  the  surface  may  be  soft  and  the  central  portion,  or  that  nearest  to 
the  point  of  origin  from  the  periosteum,  may  be  firm  and  hard.  The 
progress  of  the  tumoui'  is  generally  very  slow,  and  the  firmer  varieties 
do  not,  as  a  rule,  acquire  a  very  considerable  size.  It  is  different,  how- 
ever, with  the  softer  kinds,  as  they  may  attain  a  great  raagnitude.  Thus 
Mooren*  mentions  a  fibrous  tumour  of  the  orbit  which,  after  a  former 
operation,  attained  the  size  of  a  child's  head,  and  involved  the  bones  of 
the  face  and  head.  Mr.  Critchettf  narrates  a  remarkable  case  of 
fibrous  tumour  of  the  orbit  removed  at  two  sittings.  Zehender  J  has 
also  recorded  a  case,  in  which  he  successfully  removed  a  large  fibrous 
tumour  (preserving  the  eye),  and  applied  the  chloride  of  zinc  paste  on 
a  strip  of  plaster  to  the  bottom  of  the  orbit,  the  surface  of  the  leather  on 
which  the  caustic  paste  was  spread  being  turned  outwards  away  from 
the  eye,  and  the  latter  protected  by  the  interposition  of  a  thick  layer  of 
charpie.  This,  however,  only  just  sufiiced  to  save  the  eyeball  from 
the  action  of  the  paste,  as  the  outer  surface  of  the  globe  was  covered 
by  a  slight  layer  of  eschar,  the  sclerotic  remaining,  however,  un- 
injured. 

If  the  fibrous  tumours  are  small  in  size,  and  situated  near  the  edge 
of  the  orbit,  they  can  generally  be  removed  without  any  danger  ;  but 
if  they  are  large,  extend  deeply  into  the  orbit,  and  are  widely 
attached  to  the  periosteum,  either  by  a  broad  base  or  by  several 
pedicles,  operative  interference  must  be  extensive,  and  may  set  up  very 
considerable  inflammation,  extending  perhaps  to  the  periosteum  of  the 
orbit,  and  from  thence  to  the  brain.  Or  the  operation  may  be  followed 
by  fatal  erysipelas. § 

(2.)  SARCOMATOUS  (FIBRO-PLASTIC)  TUMOURS. 

Sarcomatous  tumours  are  particularly  distinguished  in  their  minute 
structure  by  the  fact  that  they  are  composed  of  various  shaped,  closely 
packed  cells,  and  a  scanty  intercellular  substance.  These  cells  vary 
much  in  size  and  form,  being  stellate,  circular,  oblong,  spindle  shaped, 
etc.     If  the  cells  contain  pigment,  it  is  termed  melanotic  sarcoma.    The 

*  Mooren,  "  Ophtlialmiatrische  Beobachtungen,"  p.  41. 
t  "  Med.  Times  and  Gazette,"  1852,  p.  465. 
j  "A.  f.  O.,"  iv,  2,  55. 
§  Vide  Mackenzie,  p.  327. 


SARCOMATOUS   (FIBRO-PLASTIC)   TUMOURS.  641 

fibro-plastic  variety  show  marked  spindle-sliaped  cells  with  a  large 
ovoid  nucleus  and  long,  perhaps  subdivided,  filamentous  extremities. 
On  account  of  this  peculiar  shape  of  the  cell,  and  these  long  terminal 
projections,  it  was  formerly  supposed  that  the  connective  tissue  was 
formed  by  a  division  of  these  cells.  But  this,  as  Virchow*  points 
out,  is  erroneous,  for  it  is  the  special  characteristic  of  these  tumours 
that  their  cells  persist  as  cells,  and  do  not  become  developed  into  con- 
nective tissue ;  for  if  this  development  took  place,  and  a  considerable 
formation  of  fibrillar  intercellular  substance  really  occurred,  and  if  the 
cells  were  transformed  into  fibres,  the  tumour  would  simply  be  a 
fibroma  and  not  sarcomatous.  In  fact,  the  fibro-plastic  tumour  is 
nothing  but  a  spindle-shaped  celled  sarcoma.  The  malignant  fibrous 
and  recurrent  fibroid  tumours  of  Paget  are  also  varieties  of  sarcoma. 
The  amount  of  the  fibrillar  intercellular  substance  varies  considerably 
in  quantity.  In  some  cases,  it  is  firm  and  dense,  in  others,  on  account 
of  the  great  development  of  the  cells,  it  may  have  nearly  disappeared  ; 
in  the  latter  case,  the  tumour  is  very  soft  and  becomes  medullary. 

Sarcomatous  tumours  are  not  benign  in  character,  but  show  a  great 
tendency  to  infection  of  neighbouring  organs,  commencing  first  in  the 
homologous  tissues,  and  then  passing  on  to  the  heterologous.  But  they 
also  affect  distant  organs,  and  as  the  lymphatic  glands  frequently  remain 
unaffected,  it  has  been  supposed  that  the  infection  is  carried  more  by 
the  blood  than  by  the  lymphatic  vessels. 

According  to  Yirchow,  the  sarcomatous  tumours  of  the  orbit  "  are 
generally  developed  fi^om  the  adipose  cellular  tissue  behind  the  eye, 
after  a  time  pushing  the  eyeball  out  of  the  orbit,  and  appearing  beneath 
the  conjunctiva  in  the  form  of  round,  firm  protrasions,  finally  assuming 
a  fungoid  character.  Their  commencement  may  often  be  traced  to 
distinct  traumatic  causes.  If  no  operation  is  performed,  the  eye  is  in 
the  end  destroyed  by  pressure  or  inflammation,  and  at  the  best  becomes 
atrophied.  Or  again,  the  fungus  may  grow  inwards,  reach  the  dura 
mater,  invade  the  cranium,  and  generally  ends  in  metastases,  amongst 
which,  those  of  the  bones  of  the  skull,  are  the  most  remarkable.  Most 
of  the  orbital  sarcomata  have  a  softish  consistence,  and  belong  to  the 
melano-,  myxo-,  or  gliosarcomata.  They  are  generally  multi-cellular. 
But  even  those  consisting  of  smaller  cells  may  be  operated  upon  with 
success."t  Frequently,  the  sarcomatous  tumours,  especially  melanotic 
sarcoma,  originate  in  the  eyeball,  and  subsequently  make  their  way  into 
the  orbit. 

The  great  danger  of  the  disease  is  its  extension  into  the  neighbour- 
ing cavities,  the  bony  walls,  which  separate  these  from  the  orbit,  being 
destroyed  by  caries  or  necrosis,  or  worn  through  by  the  pressure  of  the 
tumour.     In  such  a  case,  the  extension  of  the  growth  in  an  outward 
*  "  Krankhafte  Geschwiilste,"  ii,  1,  180.  f  lb.,  p-  349. 

2  T 


642  DISEASES   OF   THE   ORBIT. 

direction  may  be  slow  and  protracted.  The  operator  thinking  that 
he  has  only  to  deal  with  a  moderate,  sharply  defined  tumour,  is  sur- 
prised to  find  it  extending  far  into  neighbouring  cavities,  in  which  it 
has  perhaps  reached  a  very  considerable  size  (Stellwag). 

But  the  tumour  may  be  originally  developed  in  some  other  cavity, 
as  for  instance  the  nasal  fossa,*  or  antrum  of  Highmore,t  and  extend 
thence  into  the  orbit. 

These  tumours  are  very  apt  to  recur,  and  may  have  to  be  operated 
upon  several  times.  Thus  in  a  case  narrated  by  ]\Ir.  Quain  he  operated 
three  times. J  If  the  sight  is  unaffected,  we  should  endeavour  to 
remove  the  tumour  without  sacrificing  the  eyeball,  and  in  order  that  all 
remains  of  the  morbid  growth  may  be  removed,  the  chloride  of  zinc 
paste,  spread  upon  strips  of  lint,  should  be  inserted  into  the  wound,  care 
being  taken  that  the  dry  side  of  the  lint  is  turned  towards  the  eye,  and 
the  latter  should  be  still  further  protected  by  the  interposition  of  layers 
of  charpie.  That  the  caustic  may  be  applied  without  injury  to  the 
eyeball  or  its  muscles  was  already  shown  in  Zehender's  case  ;  Mr.  Hulke§ 
has  more  lately  published  a  similar  instance. 

But  where  the  disease  is  extensive,  the  eyeball  lost,  or  there  is  no 
doubt  as  to  the  malignant  natui"e  of  the  disease,  the  globe  must  be 
excised  with  the  tumour,  and  the  latter  should  be  as  thoroughly  removed 
as  possible.  But  the  excision  of  the  morbid  growth  with  the  knife 
and  blunt-pointed  curved  scissors  alone,  will  not  sufiice  in  cases  where 
the  tumour  is  of  a  sarcomatous  or  carcinomatous  nature,  and  iafiltrates 
more  or  less  the  neighbouring  structures;  for  then  it  cannot  with  certainty 
be  completely  removed,  and  remnants  of  tumour  are  sure  to  be  left  behind. 
The  surgeon  should  endeavour  to  remove  as  much  as  possible  of  the 
morbid  growth  by  chipping  it  away  from  the  walls  of  the  orbit,  explor- 
ing beforehand  with  the  finger  the  mass  which  he  is  about  to  excise. 
If  the' walls  of  the  orbit  are  also  affected,  the  periosteum,  or  even  por- 
tions of  the  diseased  bone,  may  be  readily  removed  with  the  elevator. 
In  order  to  check  the  haemorrhage,  and  to  destroy  any  remaining  portions 
of  the  morbid  growth  which  could  not  be  reached  with  the  scissors,  the 
hot  iron  should  be  applied  to  the  wounded  surface,  and  then,  when  all 
bleeding  has  ceased,  the  chloride  of  zinc  paste,  spread  upon  strips  of 
lint,  is  to  be  applied  to  the  wound.  The  chloride  of  zinc  paste  has 
been  used  extensively,  and  most  successfully,  at  the  Middlesex  Hospital, 
where  the  follo\^ang  formula  is  generally  employed : — One  part  by 
weight  of  chloride  of  zinc  is  rubbed  up  with  four  parts  of  flour,  to 
which  sufficient  tinctura  opii  is  added  to  make  a  paste  of  the  con- 
sistence of  honey. 

*  Gracfc,  "A.  f.  O.,"  i,  1,419. 

+  Pagcnstecher,  "  Klinischc  Bcobachtimp;en,"  i,  76,  1861. 
X  "  Med.  Times,"  1854,  No.  204.  §  "  E.  L.  O.  H.  Kep.,"  v,  4,  346. 


OSSEOUS   AND   CARTILAGINEOUS   TUMOURS.  G43 

To  many  surgeons  the  use  of  the  hot  iron  and  of  an  escharotic  to 
the  orbit  will  appear  a  most  dangerous  proceeding,  on  account  of  the 
thinness  of  the  roof  of  the  orbit,  which  divides  it  from  the  brain. 
Bat  experience  proves  that  this  pi*oceediug,  if  carefully  and  expertly 
performed,  is  not  fraught  with  any  particular  risk,  for  the  action  of  the 
hot  iron  is  superficial,  and  that  of  the  chloride  of  zinc  can  be  also 
very  well  regulated.  Moreover,  it  produces  little  or  no  constitutional 
distiu'bance,  and  only  excites  slight  inflammation  of  the  living  tissues 
beyond  the  slough.  The  truth  of  these  statements  is  sufficiently  proved 
by  the  very  remai'kable  cases  in  which  this  line  of  treatment  has  been 
pursued  by  Mr.  De  Morgan,  Mr.  Moore,  Mr.  Hulke,  and  Mr.  Lawson, 
and  which  have  been  brought  before  the  notice  of  the  jirofession  at  dif- 
ferent periods. 

Mr.  Hulke*  reports  a  very  interesting  case  of  large  fungating  mela- 
notic sarcoma  which  had  become  developed  from  a  shrunken  eyeball, 
filled  the  cavity  of  the  orbit,  and  protruded  between  the  eyelids, 
which  was  successfully  extirpated  with  the  aid  of  the  actual  cautery 
and  chloride  of  zinc  paste. 

A  veiy  interesting  and  important  case  of  recurrent  fibroid  tumour, 
which  has  been  operated  upon  several  times  by  Mr.  Lawson,  is  recorded 
in  the  forthcoming  number  of  the  "  R.  L.  0.  H,  Reports." 

(3.)  FATTY  TUMOURS  OF  THE  ORBIT. 

The  fatty  tumours  are  developed  in  the  adipose  cellular  tissue  of  the 
orbit,  either  in  its  cavity  or  between  the  recti  muscles,  just  beneath  the 
conjunctiva.  They  generally  occur  in  early  life,  and  are  sometimes 
perhaps  congenital.  They  increase  slowly  in  growth,  are  not  accom- 
panied by  any  symptoms  of  pain  or  inflammation,  and  vary  much 
in  size  and  consistence.  The  latter  will  depend  upon  the  relative 
amount  of  the  fatty  material,  and  the  firmness  and  quantity  of  the 
fibro-cellular  tissue.  They  are  often  very  elastic  to  the  touch,  and  give 
rise  to  a  sense  of  fluctuation,  which  may  deceive  us  as  to  their  true 
nature,  and  cause  them,  perhaps,  to  be  mistaken  for  a  cyst.  No  diffi- 
culty is  generally  experienced  in  their  removal,  which  should,  if  possible, 
be  done  from  within  the  eyelid. 

(4.)  OSSEOUS  AND  CARTILAGINEOUS  TUMOURS. 

According  to  Mackenzie,t  we  may  distinguish  three  forms  of 
exostosis  of  the  orbit:  1,  the  cellular;  2,  the  craggy,  or  semi- car tilagi- 

*  Hulke  on  Orbital  Tumours,  "  R.  L.  O.  H.  Rep.,"  v,  3,  181. 
t  "  Treatise  on  Diseases  of  the  Eye,"  4th  edition,  p.  41. 

2   T   2 


(344  DISEASES   OF   THE   ORBIT. 

neons ;  3,  the  ivory.  The  celkilar  exostosis  is  characterised  by  its 
being  composed  of  an  osseous  crust,  which  surrounds  a  softish  substance? 
traversed  by  numerous  dehcate  bony  partitions.  Sometimes,  it  may 
contain  hydatids.  This  form  of  exostosis  springs  from  the  periosteum, 
does  not  generally  acquire  a  considerable  size,  and  may  remain  quite 
stationary.  The  craggy,  or  semi-cartilagineous  exostosis  generally  con- 
sists in  the  centre  of  osseous  laminae,  which  are  surrounded  by  cartilage, 
over  which  the  periosteum  may  be  imperfectly  traced,  but  it  has  no 
complete  shell.  It  may  grow  from  the  cancelli  or  from  the  periosteum. 
The  ivory  exostosis  is  the  form  most  frequently  met  with  in  the  orbit ; 
it  is  excessively  hard,  and  consists  of  perfectly  developed,  dense,  and 
very  firm  bone  tissue.  According  to  Mackenzie,  it  originates  in  the 
diploe,  presses  the  compact  tissue  of  the  bone  before  it,  and  forms  a 
round,  smooth,  or  somewhat  nodulated  tumour.  It,  moreover,  shows  a 
disposition  to  extend  into  the  cranium. 

Exostosis  frequently  supervenes  upon  periostitis  and  ostitis,  and 
may  be  due  to  a  scrofulous  or  syphilitic  diathesis,  or  be  produced  by 
injuries,  such  as  falls  or  blows  upon  the  orbit,  or  by  fractures  of  the 
latter. 

These  osseous  tumours  are  more  or  less  hard  to  the  touch,  slow  in 
their  progress  and  growth,  and  generally  accompanied  by  little  or  no 
pain  or  inflammatory  symptoms.  Sometimes,  the  pain  may,  however,  be 
severe,  more  especially  if  symptoms  of  periostitis  supervene  in  the 
course  of  the  disease.  The  degree  of  exophthalmos  and  impairment  of 
the  movements  of  the  eye  will  vary  with  the  extent  and  situation  of  the 
exostosis.  It  is  often  quite  impossible  to  determine  the  exact  nature  of 
the  disease  before  operation,  more  especially  when  the  tumour  is 
situated  deep  in  the  orbit.  Ivory  exostosis  is  frequently  developed  from 
the  frontal  or  ethmoid  bone. 

In  the  early  stage,  the  treatment  should  be  directed  to  promote  the 
absorption  of  the  tumour,  by  the  administration  of  the  iodide  of  potas- 
sium internally,  the  application  of  mercurial  ointment  over  the  brow, 
etc.  The  patient's  general  health  must  be  attended  to,  and  kept  up  by 
a  generous  diet  and  tonics,  residence  in  the  country  or  at  the  sea 
side,  etc. 

If  the  exostosis  is  small  and  remains  stationary,  it  should  not  be 
interfered  with  by  operation.  But  if  it  is  increasing  in  size,  and  is 
producing  exophthalmos,  etc.,  the  surgeon  should  endeavour  to  re- 
move it. 

The  tumour  should  be  freely  exposed  by  one  or  more  incisions, 
carried  through  the  integuments  and  between  the  fibres  of  the  orbicu- 
laris, or,  if  necessary,  by  dissecting  back  the  lids.  In  order  to  gain 
plenty  of  room,  it  may  also  be  necessiiry  to  divide  the  outer  commissure 
of  the  lids.     The  tumour  having  been  thus  exposed,  is  to  be  stripped  of 


CYSTIC   TUMOURS   OF   THE   ORBIT.  645 

its  periosteum,  and  carefully  excised  with  a  scalpel,  assisted  by  cutting* 
pliers  and  strong  bone  forceps.  Great  care  must  be  taken  not  to 
injui^e  the  upper  and  inner  wall  of  the  orbit  by  a  rough  and  thoughtless 
use  of  the  instruments.  The  ivory  exostoses  are  frequently  so  firm  and 
hard,  and  so  intimately  and  widely  connected  with  the  bone,  that  it  may 
be  impossible  to  complete  the  operation,  and  the  latter  must  be  desisted 
from.  Mr.  Haynes  Walton  narrates  a  case  in  which  he  successfully 
removed  a  large  ivory  exostosis.*  Two  similar  instances  are  recorded 
by  Maisonneuve. 

Sometimes,  however,  the  tumour  is  so  excessively  hard,  and  its 
attachment  so  extensive,  that  it  resists  all  the  efforts  made  with  the 
saw,  cutting  pliers,  or  mallet ;  little  splinters  of  bone  may  be  chipped 
off,  but  the  great  mass  of  the  growth  is  impregnable,  and  the  opera- 
tion has  to  be  abandoned.  Such  instances  have  been  recorded  by 
Mackenziet  and  Knapp.|  In  Knapp's  case,  seven  weeks  after  the 
operation,  the  first  five  having  been  passed  very  quietly  and  favourably, 
the  patient  was  attacked  with  symptoms  of  meningitis,  of  which  she 
died.  On  post  mortem  examination,  a  general  thickening  of  the  cranium 
was  discovered,  together  with  a  large  exostosis,  about  the  size  of  a 
goose's  egg,  springing  from  the  frontal  bone.  In  a  subsequent  case  of 
ivory  exostosis,  Knapp  succeeded  in  removing  the  tumour.  § 

The  true  cartilagineous  tumours  (enchondroma),  are  only  very  rarely 
met  with  in  the  orbit.  Many  of  the  cases  which  have  been  recorded 
Tinder  this  name,  were  in  reality  instances  of  osteo-steatoma  or  osteo- 
sarcoma. This  mistake  is  the  more  easily  made,  as  some  of  these 
tumours  in  the  course  of  their  development  undergo  cartilagineous 
changes  before  becoming  ossified. 

Although  these  cartilagineous  tumours  as  a  rule  spring  from  the 
bone,  they  may  also  become  developed  from  tbe  softer  tunics  of  the 
orbit.  They  are  most  frequently  met  with  in  youthful  individuals.  In 
a  case  of  Von  Graefe's||  it  occurred  in  a  child  only  seven  months  old,  it 
being  stated  that  the  tumour  had  existed  since  the  first  month  after 
birth. 

(5.)  CYSTIC  TUMOURS  OF  THE  ORBIT. 

Cysts  may  occur  at  various  parts  of  the  orbit,  either  deep  in  its 
cavity  behind  the  eyeball,  or  near  its  upper  or  lower  margin.  Whilst 
some  of  these  cysts  contain  hydatids,  others  are  developed  from  the 
follicles  of  the  lids.  At  first,  their  true  nature  may  be  readily  recog- 
nizable,  but  when   they   attain   a   considerable    size,    the   connection 

*  "  Surgical  Diseases  of  the  Eye,"  286. 
t  L.  c.,  48.  t  "  A.  f.  O.,"  viii,  1,  239. 

§  "  Kl.  Monatsbl.,"  1865,  376.  ||  "  A.  f.  O.,"  i,  1,  415. 


646  DISEASES  OP  THE   ORBIT. 

between  the  cyst  and  the  follicle  may  become  so  attenuated,  stretched, 
or  even  torn  through,  that  their  real  mode  of  origin  is  often  overlooked. 
The  consistence  and  contents  of  these  follicular  cysts  are  subject  to 
considerable  variations.  Thus  in  the  atheromatous  form,  the  contents 
are  of  a  friable,  cheesy,  or  curdy  nature ;  whereas,  in  the  steomatous 
they  rather  resemble  suet. 

Other  cysts  spring  from  the  glandular  structures  of  the  conjunctiva, 
and  may  contain  a  yellow,  serous,  or  rather  viscid  and  albuminous 
fluid,  like  white  of  egg  (the  latter  kind  of  cyst  is  termed  hygroma). 
They  may  be  about  the  size  of  a  pea  or  bean,  and  situated  near  the 
surface  of  the  conjunctiva.  But  they  sometimes  extend  back  into  the 
orbit,  attain  a  very  considerable  size,  and  then  give  rise  to  great 
exophthalmos.  In  rare  instances,  the  cysts  contain  a  brown  hEemorr- 
hagic  fluid. 

Some  orbital  cysts  have  been  found  to  have  hairs,  etc.,  growing 
from  their  internal  walls. 

Two  kinds  of  hydatids  are  met  with  in  the  orbit,  the  echinococcus, 
and  the  cysticercus.  The  former  is  much  larger,  and  occurs  in 
greater  numbers  than  the  cysticercus.  Thus  the  echinococcus  may 
acquire  the  size  of  a  filbert,  and  be  present  in  great  quantities,  causing 
an  excessive  protrusion  of  the  eye.  In  a  case  of  Lawrence's,  quoted  by 
Mackenzie,*  half  a  teacup-full  of  echinococci,  varying  in  size  from  a  pea 
to  a  filbert,  were  emptied  from  an  orbital  cyst.  Mr.  Bowmanf  ope- 
rated upon  a  somewhat  similar  case,  in  which  three  hydatids  came 
away  a  few  days  after  the  operation.  Two  were  as  big  as  large 
marbles,  the  third  about  half  the  size.  In  a  case  of  Waldhauer's,;|:  some 
of  the  hydatids,  of  which  there  was  a  great  quantity,  had  acquired  the 
size  of  a  hazel  nut.  The  hydatid  is  enclosed  in  a  capsule  of  thickened 
connective  tissue,  besides  the  proper  cyst  wall.  The  cysticerci  are 
m.uch  smaller  in  size  than  the  echinococci,  and  their  cyst  wall  much 
slighter  and  thinner. 

Cystic  tumours  of  the  orbit  are  generally  slow  in  their  progress, 
and  may  remain  but  small  in  size ;  if  they  however  grow  considerably, 
the  eyeball  will  gradually  be  protruded.  Their  development  is  generally 
unaccompanied  by  any  pain,  but  when  they  are  very  large,  and  have 
caused  great  exophthalmos,  the  sufierings  of  the  patient  are  often  most 
intense,  the  pain  extending  perhaps  over  the  corresponding  side  of  the 
head  and  face.  The  tumour  is  not,  however,  tender  to  the  touch.  If 
the  cyst  is  situated  near  the  front  of  the  orbit,  so  that  it  can  be  seen 
and  felt,  it  will  present  a  round  or  ovoid  appearance,  of  varying  size, 
and  is  observed  to  be  quite  unconnected  with  the  eyeball.  If  the  cyst- 
wall  is  thin  and  soft,  the  tumour  will  be  very  elastic  to  the  touch,  and 

*  Mackenzie,  1087.  f  lb.,  1088. 

t  "  KI.  Monatsbl.,"  18G5,  p.  385. 


CYSTIC   TUMOURS   OF   THE   ORBIT.  G47 

distinctly  fluctuating.  If  firm  pressure  is  applied,  it  may  perhaps 
be  made  to  recede  into  the  orbit,  re-appearing,  however,  when  the 
pressure  is  relaxed.  If  the  cyst  wall  is  thick,  or  the  integuments  over 
the  tumour  are  swollen,  the  latter  will  on  a  superficial  examination 
feel  somewhat  firm,  the  fluctuation  being  only  discovered  on  deeper 
pressure. 

If  any  doubt  exists  as  to  the  nature  of  the  tumour,  an  exploratory 
puncture  or  incision  should  be  made,  and  then  if  the  cyst  is  found  to 
be  only  moderate  in  extent  and  not  reaching  very  far  back,  and  if  its 
contents  are  dense,  it  should  be  excised,  which  is  best  done  by  dissecting 
it  out  with  the  aid  of  a  silver  knife,  or  the  end  of  the  handle  of  a  scalpel, 
assisted  by  the  finger.  If  the  contents  are  fluid,  and  the  cyst  is  large, 
it  will  be  better  to  empty  it  (if  necessary,  repeated  several  times)  by 
an  incision,  and  then  to  permit  it  to  close  by  adhesive  inflammation. 
Sometimes  strips  of  lint  ai^e  inserted,  thus  setting  up  suppurative 
inflammation  ;  but  this  is  dangerous  if  the  cyst  extends  deeply  into  the 
orbit,  as  the  inflammation  might  extend  to  the  lining  membranes  of  the 
brain.  Injections  of  iodine  have  been  recommended,  but  they  are  also 
accompanied  by  considerable  risk. 

I  may  state  that  at  the  commencement  of  the  disease  it  is  often 
extremely  difficult,  or  even  impossible  to  diagnose  with  anything 
like  certainty,  whether  the  nature  of  the  orbital  tumour  is  benign  or 
malignant.  There  are,  however,  certain  points,  which  may  assist  us 
in  oilr  diagnosis.  Thus,  in  malignant  afiections,  the  general  health  of 
the  patient  mostly  sufiers  considerably  even  at  an  early  stage  ;  whereas, 
in  the  benign  tumours  this  is  not  the  case,  the  patient  retaining  good, 
and  even  blooming  health,  excepting  indeed  the  tumour  has  attained 
a  very  considerable  size,  and  produces  great  pain  by  pressing  upon  the 
eyeball,  or  stretching  the  nerves. 

The  progress  of  a  maligTiant  tumour  is  also,  as  a  rule,  much  more 
rapid  that  when  it  is  benign.  The  rapidity  of  its  growth  will,  how- 
ever, vary  according  to  circumstances.  Thus,  as  long  as  it  is  confined 
to  the  posterior  portion  of  the  orbit,  the  pressure  of  the  eyeball  offers  a 
certain  degree  of  check  to  its  development,  and  somewhat  restrains  its 
rapid  growth.  The  same  is  the  case  in  intra-ocular  mahgnant  tumours, 
whose  progress  may  be  comparatively  very  slow  as  long  as  they  are 
confined  by  the  external  coats  of  the  eye ;  Imt  when  these  have  once 
given  way,  and  the  tumour  sprouts  forth,  its  increase  in  size  is  always 
most  marked  and  rapid.  The  pain  is  also  much  more  intense  and 
continuous  in  malignant  tumours,  but  this  symptom  is  not  very  re- 
liable, for  even  in  benign  tumours  it  may  be  very  severe,  if  the  eye  is 
much  protruded. 

Yon  Graefe*  lays  great  importance  upon  the  degree  to  which  the 
*  "  A.  f.  O.,"  X,  1,  194. 


648  DISEASES  OF   THE   ORBIT. 

muscles  of  the  eye  and  their  nerves  are  implicated,  as  a  point  of 
diagnosis  between  benign  and  malignant  tumours  of  the  orbit.  Malig- 
nant growths,  according  to  him,  always  cause  a  much  greater  and 
earlier  impairment  of  the  movements  of  the  eye,  so  that  the  latter  may 
be  already  almost  immoveable,  whilst  the  exophthalmos  is  yet  but  slight 
in  degree.  In  estimating  the  amount  of  immobility,  we  must,  of  course, 
take  into  consideration  the  mechanical  effect  of  the  tumour,  and  the 
change  of  position  of  the  eyeball. 

The  skin  and  neighbouring  parts  are  more  frequently  affected  in 
malignant  tumours,  so  that  the  boundaries  of  the  latter  cannot  be  so 
exactly  made  out,  and  the  skin  is  not  so  moveable  over  them.  Malig- 
nant growths  of  the  orbit  are  also  of  more  common  occurrence  in 
children  than  in  adults.  Thus  Leber  has  found  that  in  one- third  of  the 
cases  of  cancer  of  the  eye  and  orbit,  the  patients  were  under  ten  years 
of  age. 

Whether  or  not  the  tumour  springs  from  the  eye  or  is  continuous 
with  it,  may  be  estimated  by  the  nature  of  the  movements  of  the  eye- 
ball. If  the  movements  take  place  round  the  turning  point  of  the 
protruded  eye,  it  proves  that  the  normal  layer  of  connective  tissue 
between  the  posterior  hemisphere  of  the  eyeball  and  the  tumour  still 
exists.  Whereas,  if  the  tumour  and  the  globe  are  continuous,  the 
movements  will  not  be  round  the  turning  point  of  the  eye  (Graefe). 

Cancerous  tumours  of  the  orbit  may  be  developed  from  the  walls 
of  the  latter,  from  the  adipose  cellular  tissue,  or  may  extend  into  the 
orbit  frora  neighbouring  cavities  or  from  the  eyeball. 

The  medullary  and  melanotic  cancer  are  far  more  frequently  met 
with  in  the  orbit  than  scirrhus. 


(6.)  SCIRRHUS. 

Scirrhus  of  the  orbit  is  generally  due  to  some  injury,  or  to  prior 
inflammation.  It  may  show  itself  in  the  form  of  one  large  scirrhous 
mass  implicating  the  whole  of  the  orbit,  or  in  the  form  of  small,  cir- 
cumscribed, hard  tumours,  which  closely  resemble  exostoses  in  their 
appearance.  Its  growth  is  generally  slow,  and  not  accompanied  by 
much  or  severe  pain. 

The  following  case  of  scirrhus  tumour  of  the  orbit  is  of  rare  im- 
portance and  interest,  as  illustrating  the  great  benefit  to  be  derived 
from  extirpation,  followed  by  the  application  of  the  hot  iron  and  chloride 
of  zinc  paste. 

A  woman,  aged  48,  upon  her  admission  into  the  Middlesex  Hospital 
under  Mr.  Lawson,  January  30th,  18GG,  had  her  left  eye  protruded  a 
full  inch  beyond  its  fellow  by  a  hard  solid  growth,  which  could  be  dis- 


SCIRRHUS. 


G49 


tinctly  felt  with  the  finger  to  be  filling  the  orbit.  The  surface  of  the 
cornea  was  ulcerated,  and  the  eye  had  only  perception  of  light.  The 
upper  hd  could  not  close  over  the  globe.  About  four  months  before  her 
admission  a  hard  scirrhous  tubercle  was  noticed  in  front  of  the  ear,  it  was 
now  about  the  size  of  a  bean.  Mr.  Lawson  excised  the  eyeball  and  the 
whole  of  the  cancer  down  to  the  orbital  walls,  and  then  applied  the  actual 
cautery  to  arrest  the  bleeding.  Strips  of  lint,  covei-ed  with  chloride  of 
zinc  paste,  were  then  applied 
to  the  bottom  of  the  orbit  and 
arouud  its  walls.  He  next 
excised  the  tubercle  on  the 
face,  and  also  applied  to  this, 
after  all  bleeding  had  ceased, 
the  chloride  of  zinc  paste. 
Large  superficial  sloughs  were 
at  first  detached,  and  in  about 
three  months  afterwards  the 
whole  bony  orbit  became  com- 
pletely detached,  and  Mr.  Law- 
son  pulled  it  away  in  one  piece 
(Fig.  87).*  The  exact  size  and 
appearance  of  the  orbit  after 
its  removal  are  here  very  cor- 
rectly represented.  It  is  now 
in  the  museum  of  the  Mid- 
dlesex Hospital.  The  patient 
had  a  good  deal  of  pain  in  the 
head  and  sickness  during  the 
separation  of  the  bone  from 
the  neighbouring  tissues,  but 
all  these  symptoms  at  once 
ceased  after  the  orbit  had 
come  away. 

Up  to  this  date,  November 
1868,  nearly  3  years  after  the 
operation,  she  is  still  perfectly 
well,  and  has  had  no  recur- 
rence of  the  disease.  Her 
present  appearance  is  well 
illustrated  in  Fig.  88.t 


Tiff.  88. 


*  Transactions  of  the  Pathological  Society,  1867,  p.  233. 

+  These  woodcuts  (whicli  were  kindly  lent  by  Mr.  Lawson  to  the  author),  are 
from  photographs  by  Mr.  Heisch. 


G50  DISEASES   OP   THE   ORBIT. 


(7.)  MEDULLARY  CAXCER. 

This  is  especially  distinguislied  by  its  soft  consistence,  which  greatly 
resembles  that  of  rice,  by  the  peculiar  cauliflower  excrescences,  or  the 
red  fleshy,  fungous  appearance  (fungus  haematodes)  whicb  it  presents 
when  protruding  from  the  orbit.  The  form  of  the  tumour  may  be 
tolerably  circumscribed,  and  it  may  not  be  very  adherent  to  the  perios- 
teum ;  or  it  may  be  closely  connected  with  the  latter,  also  invading  and 
destroying  the  muscles  of  the  eye,  the  periosteum,  and,  finally,  the 
bones  of  the  orbit,  and  then  extending  into  the  neighbouring  cavities. 
It  may  likewise  extend  along  the  optic  nerve  to  the  brain. 

The  tumour  may  grow  with  considerable  rapidity,  and  attain  an 
enormous  size,  and  this  is  especially  the  case  when  it  recurs,  after  the 
eveball  and  the  primary  tumour  have  been  extirpated. 

The  following  case  of  Mr.  De  Morgan's  graphically  illustrates  the 
appearances  presented  by  such  a  tumour,  as  well  as  the  mode  of  treat- 
ment which  should  be  adopted,  and  which  proved  successful  for  a  period 
of  14  months,  when  the  patient  died  from  a  secondary  tumour  in  the 
cranium,  the  disease  having  travelled  back  along  the  optic  nerve. 

The  patient,*  James  Yinall,  was  33  years  of  age,  healthy,  and  also 
of  a  healthy  family,  when  he  received,  in  August,  1863,  a  blow  on  the 
left  eye.  In  two  months  the  sight  became  impaired,  and  there  was 
deep-seated  pain  in  the  orbit,  and  in  February,  1864,  he  was  quite 
blind  in  this  eye.  Mr.  Woolcott  detected  an  intra-ocular,  cancerous 
growth,  and  removed  the  eye  on  20th  April.  The  parts  healed  rapidly, 
and  his  health  improved.  In  May  he  had  again  severe  darting  pain 
at  the  back  of  the  orbit,  and  shortly  afterwards  a  tumour  protruded 
between  the  lids.  The  morbid  growth  increased  with  great  rapidity, 
and  his  health  and  strength  failed  greatly.  In  August,  the  tumour 
began  to  bleed,  and  the  haemorrhage  recurred  daily.  In  October,  a 
piece,  about  the  size  of  a  large  walnut,  dropped  off  from  the  centre  of 
the  mass.  He  became  a  patient  in  the  Middlesex  Hospital  on  N^ovember 
3,  1864.  Mr.  De  Morgan  gives  the  following  description  of  the  tumour 
and  the  operation  performed  upon  it : — 

"  A  large,  irregular  tumour  projected  from  the  orbit,  excavated  in 
the  centre,  and  sloughing  (see  Fig.  89).  The  margins  of  the  lids  could 
be  traced  over  it,  spread  out  and  stretched  to  a  remarkable  degree.  At 
the  lower  and  outer  part,  the  tumour  involved  the  structure  of  the 
cheek.  Its  general  surface  was  somewhat  flattened  and  circular,  and 
measured  four  inches  across.  It  projected  nearly  four  inches  forward 
from,  the  cheek  on  the  outside,  and  about  two  inches  and  three-quarters 
from  the  nasal  side.     No  alteration  could  be  detected  in  the  cranial 

*  "  Pathological  Society's  Transactions,"  18G6,  265. 


MEDULLARY  CANCER. 


651 


bones  ;  nor  were  any  diseased  glands  to  be  felt.     The  patient  bad  never 
had  any  cerebral  symptoms.     He  was  in  a  wretched  state  of  health 


Fig.  89. 


from  continued  bleeding  and  offensive  discharge,  and  from  severe  and 
constant  pain.  As,  at  two  hospitals,  the  surgeons  who  saw  him  declined 
to  operate,  he  was  fully  impressed  with  the  hopelessness  of  his  case, 
but  he  was  anxious  to  have  anything  done  to  free  him  for  a  time  from 
the  pain  and  discharge.  With  this  view  I  consented  to  operate,  antici- 
pating only  a  short  reprieve  from  death,  but  hoping  that  I  might  be 
able  by  destroying  the  disease  as  it  sprouted  again,  to  give  him  some 
relief  and  comfort.  The  success  which  attended  Mr.  Moore's  operation 
on  the  case  of  rodent  ulcer,  brought  before  the  British  Medical  Associa- 
tion, determined  me  to  follow  the  same  plan,  and  thus  destroy  the 
disease  as  effectually  as  I  could.  I  removed  the  tumour  on  the  23rd  of 
November,  1864,  by  first  cutting  the  mass  from  the  orbit  with  strong 
curved  scissors,  and  then  removing  all  the  parts  to  which  the  growth 
extended  external  to  the  Uds  themselves.  The  actual  cautery  was  then 
freely  applied  over  the  whole  surface  of  the  orbit  and  parts  around, 
and  finally  the  whole  was  covered  with  a  layer  of  cotton- wool,  thickly 
coated  with  the  chloride  of  zinc  paste. 

"  There  was  very  little  haemorrhage,  and  he  scarcely  had  pain  after 
the  operation.  In  a  fortnight  a  large  mass  of  the  charred  tissue  was 
thrown  off,  \\Tith  some  parts  of  the  orbital  bones.  Portions  of  the  bones 
of  the  orbit  exfoliated  from  time  to  time,  until  much  of  the  framework 


052 


DISEASES   OP   THE   ORBIT. 


Fm.  90. 


came  away,  exposing  in  one  part  the  dura  mater,  and  opening  the  nasal 
and  maxillary  cavities.  Healthy  granulations  soon  covered  the  whole 
surface.  He  rapidly  gained  health  and  strength.  One  or  two  little 
millet-seed  looking  excrescences  remained  at  the  inner  part  of  the  wall 
of  the  cavity,  but  they  did  not  appear  to  grow ;  from  time  to  time, 
however,  they  were  touched  with  the  chloride  of  zinc,  or  nitrate  of 
silver." 

In  September,  1865,  he  again  applied,  suffering  from  severe  rheu- 
matic pains  in  the  right  hip ;  he  had  lost  flesh,  and  the  pulse  was 
up  to  100.  The  excrescences  on  the  inside  of  the  orbit  having  increased 
in  size  (one  was  as  large  as  a  small  nut),  were  cut  away  by  Mr.  De 
Morgan,  and  the  tissue  around  them  destroyed  by  the  chloride  of 
zinc. 

The  microscopic  examination  of  the  tumour,  made  by  Mr.  Hulke, 
showed  it  to  be  medullary  cancer.  The  optic  nerve  appeared  healthy 
on  section ;  but  extending  between  the  inner  and  outer  sheath  in  the 
loose  connective  tissue,  were  small  diffused  patches  of  cancer  elements, 
lying  in  the  meshes  of  the  healthy  tissue. 

Fig.  90  shows  the  pa- 
tient's condition  when  he 
appeared  before  the  Patho- 
logical Society,  on  Feb.  6th, 
1868.*  He  was  then  appa- 
rently quite  well. 

Although  the  patient 
appeared  to  be  quite  well 
in  February,  1866,  he  died 
on  July  11th,  having  lived 
1  year  and  8  months  after 
the  operation.  He  had  for 
some  time  suffered  greatly 
from  sciatica,  which  was 
soon  followed  by  paraple- 
gia. He  had  also  vertical 
hemiopia  of  the  remaining 
eye.  On  post  mortem  ex- 
amination, a  large  tumour 
was  found  in  the  middle 
fossa  of  the  skull,  growing  apparently  from  the  orbital  foramen  and 
sphenoidal  fissure,  the  optic  nei've  as  far  as  the  commissure  being 
involved  in,  and  undistinguishable  from  it.  Cancerous  deposits  were 
also  found  in  the  glands  around  the  aorta,  and  adhering  to  the  nerve 

*  Tliis  and  the  preceding  cut  are  from  photographs  by  Mr.  Heisch,  and  have 
been  kindly  lent  to  the  author  by  the  Council  of  the  Tathological  Society, 


VASCULAR   TUMOURS   OF   THE   ORBIT.  (353 

trunks  of  the  cauda  equina.     The  orbit  was  empty,  and  free  from  any 
cancerous  growth. 

The  retui'n  of  the  disease,  and  its  fatal  termination,  were  conse- 
quently only  due  to  the  fact  that  the  optic  nerve  was  involved  in  the 
cancerous  affection.  Mr.  De  Morgan  therefore  thinks  that  these  facts 
justify  the  belief,  that  had  the  operation  been  done  in  the  same 
manner  at  an  earlier  period,  the  patient  might  have  remained  well. 

(8.)  MELANOTIC  CANCER. 

Melanotic  tumours  of  the  orbit  are,  like  those  within  the  eye, 
often  either  of  a  sarcomatous  or  a  mixed  character,  one  portion  of 
the  morbid  growth  being  of  a  sarcomatous  nature,  another  carcino- 
matous. The  character  and  progress  of  melanotic  cancer  have  already 
been  given  in  the  articles  upon  tumours  of  the  choroid  (p.  448),  and 
need  not  be  entered  upon  here,  as  the  disease  does  not  differ  essentially 
in  its  course  and  nature  (excepting  its  colour)  from  other  cancerous 
affections  of  the  orbit. 

(9.)  EPITHELIAL  CANCER. 

Epithelial  cancer  of  the  orbit  is  also  occasionally  met  with,  origina- 
ting in  the  skin  of  the  temple,  cheek,  or  nose,  and  extending  from  thence 
into  the  orbit.  Mr.  Hulke*  narrates  a  most  interesting  case  of  epithe- 
lial cancer  of  the  orbit  caused  by  a  severe  blow  upon  the  cheek,  in 
which  the  symptoms  presented  by  the  disease  closely  resembled  those 
of  carbuncular  cellulitis. 


7.— VASCULAR  TUMOURS  OF  THE  ORBIT. 
(1.)  Cavernous  Tumour. 

Only  four  instances  of  this  very  rare  form  of  orbital  tumour  have 
been  recorded,  by  Lebert,t  de  Ricci,J  Yon  G-raefe,§  and  Wecker.|| 

These  tumoui's  do  not  present  any  specially  characteristic  features 
in  their  external  appearance,  excepting  that  they  are  prone  to  undergo 
marked  spontaneous  changes  in  size,  which  are  dependent  upon 
mechanical  hyperaemia  of  the  morbid  growth.     Thus,   any  straining 

*  "R.  L.  O.  H.  Rep.,"  V,  336. 

+  AbhancUungen  aus  dem  Gebiete  der  praktisclien  Chii-iirgie.  Berlin,  1848, 
p.  88. 

I  "  Dublin  Quarterly  Joui-nal,"  1865,  November,  p.  338. 
§  "A.  f.  O.,"  vii,  2,  p.  12. 

II  Weckei-,  "  Maladies  des  Yeux,"  2nd  edit.,  i,  798. 


654  DISEASES   OF   THE   ORBIT. 

or  violent  exertion,  or  stooping  position  of  the  head,  may  be  followed 
by  a  striking  increase  in  the  size  of  the  tumour.  In  Von  Graefe's  case, 
the  mere  pressure  of  the  pillow  in  bed  upon  this  side  of  the  head  and 
face  gave  rise  to  a  temporary  protrusion  of  the  eye,  accompanied 
by  great  congestion  of  the  conjunctival  and  subconjunctival  vessels. 

The  growth  of  these  tumours  is  generally  slow,  more  especially  if 
they  are  situated  deeply  in  the  orbit,  for  then  the  pressure  of  the  eyeball 
restrains  their  rapid  development. 

The  cavernous  tumour*  is  surrounded  by  a  capsule  of  dense  cellular 
tissue,  Avhich  is  only  very  loosely  connected  to  the  adipose  tissue  of  the 
orbit,  so  that  the  tumour  can  be  very  readily  and  completely  removed, 
with  but  a  very  slight  amount  of  hEemorrhage.  On  a  section,  it  is  seen 
to  be  of  a  spongy  nature,  and  to  be  traversed  by  delicate  meshes  of 
fibrillar  connective  tissue,  dividing  it  into  a  vast  number  of  little  com- 
partments. These  interspaces  contain  blood,  which  can  be  readily 
squeezed  out  by  a  little  pressure,  and  this  causes  a  considerable  diminu- 
tion in  the  bulk  of  the  tumour,  which  at  the  same  time  becomes  of  a 
pale  greyish  tint. 

The  erectile  tumours  (telangiectasis)  which  are  met  with  in  the  orbit, 
almost  invariably  take  their  origin  from  the  eyelids,  and  then,  increasing 
in  size,  extend  thence  into  the  orbit.  They  are  described  in  the  article 
on  Tumours  of  the  Eyelids. 

(2.)  Aneurisms  of  the  Orbit. 

Aneu7-ism  hy  anastomosis  is  of  far  less  freqixent  occurrence  in  the 
orbit  than  was  at  one  time  supposed,  and  many  of  the  cases  which  have 
been  described  under  this  name,  were  evidently  instances  of  diffuse 
aneurism.  Aneui'ism  by  anastomosis  is  met  with  principally  in  young 
children,  and  is  mostly  congenital.  The  tumour  commences  in  or  near 
the  skin,  is  connected  with  the  subcutaneous  tissue,  and  presents  the 
appearance  of  an  irregular  nodulated  growth,  consisting  of  convolutions 
of  dilated  arteries ;  the  vessels  in  the  neighbourhood  participating  in 
the  increased  action.  The  origin  of  the  tumour  is  neither  sudden  nor 
produced  by  direct  violence,  but  is  slow,  and  its  increase  in  size  is 
tardy  and  gradual.  The  size  of  the  swelling  is  much  increased  by  any 
position  or  exertion  which  causes  congestion  of  the  head,  e.g.,  stooping, 
straining,  coughing,  etc.  Although  the  tumour  presents  distinct  signs 
of  pulsation  and  thrilling,  no  effect  (or  only  a  very  tardy  one)  is  pro- 
duced upon  these  symptoms,  or  upon  the  swelling,  by  compression  of 
the  carotid  artery.  Moreover,  as  was  strongly  insisted  upon  by 
Mr.  John  Bell,  aneurism  by  anastomosis  is  not  curable  by  ligature  of 
vessels.     The  best  treatment  is   that  of  subcutaneous  ligature  of  the 

*  Yirchow,  "  Kraukliafte  Gescliwiilste,"  iii,  1,  358. 


ANEURISMS   OF   THE   ORBIT.  655 

tumour,  the  ligature  being'  either  applied  in  a  circular  manner,  so  as  to 
include  the  base  of  the  tumour  within  a  single  loop,  or  else  the  figure 
of  8  ligature  should  be  employed.  If  the  growth  is  of  considerable 
size,  and  is  divided  into  different  nodulated  portions,  these  may  be 
operated  upon  successively  by  the  ligature  ;  or  threads  saturated  with 
a  solution  of  the  perchloride  of  iron  may  be  drawn  through  the  tumour, 
so  that  they  cross  and  re-cross  each  other  in  various  directions.  These 
modes  of  operating  are  far  more  safe  than,  and  much  to  be  pre- 
ferred to,  the  injection  of  the  perchloride  of  iron,  or  other  agents  for 
the  purpose  of  producing  coagulation.  Dr.  Althaus's  treatment  by 
electrolysis  might  also  be  tried. 

True  aneurisms  of  the  orbit  are  of  rare  occurrence,  and  do  not 
attain  any  considerable  bulk,  on  account  of  the  small  size  of  both  the 
ophthalmic  ai'tery  and  the  central  arteiy  of  the  retina.  In  a  case 
recorded  by  Mr.  Guthrie,*  an  aneui-ism  of  the  ophthalmic  artery  of 
each  side,  about  the  size  of  a  large  nut,  was  discovered  after  death. 
The  ophthalmic  vein  was  greatly  enlarged,  and  obstructed  near  its 
passage  through  the  sphenoidal  fissure  by  the  great  increase  in  size  of 
the  recti  muscles,  which  had  also  acquired  an  almost  cartilagineous  hard- 
ness. Although  the  eyes  were  greatly  protruded,  the  sight  was  hardly 
affected,  and  the  exophthalmos  was  evidently  as  much  due  to  the  state 
of  the  muscles  as  to  the  dilatation  of  the  vessels.  There  was  an  audible 
hissing  noise  in  the  head,  which  was  attributed  to  aneurism.  As  the 
disease  existed  on  both  sides,  Mr.  Guthrie  did  not  propose  ligature  of 
the  carotid. 

Cases  of  aneurism  of  the  central  artery  of  the  retina  have  been 
observed  by  Graefe  (senior),  Schmidler,  and  A.  Cooper.  In  Graefe's 
case  the  central  artery  of  the  retina  was  dilated  to  the  size  of  a  stalk 
of  grass.  But  Sousf  was  in  one  case  able  to  diagnose  the  affection 
with  the  ophthalmoscope.  He  observed  in  a  woman  of  64,  a  red 
ovoid  tumour  on  the  left  optic  disc,  extending  somewhat  beyond  its 
margin,  and,  after  becoming  suddenly  narrower,  passing  over  into  one 
of  the  retinal  arteries.  It  presented  evident  signs  of  pulsation,  the 
dilatation  being  synchronous  with  the  systole  of  the  heart.  The  other 
retinal  arteries  were  very  narrow  and  threadlike,  the  veins  somewhat 
dilated. 

Diffuse  or  false  aneurism  of  the  orbit  is  of  far  more  frequent  occur- 
rence. It  may  be  either  primary  and  traumatic,  or  consecutive  in  its 
origin.  In  the  former  case,  the  walls  of  the  artery  are  torn  or  ruptured 
by  a  sudden  blow  or  wound  of  the  head  or  orbit,  or  a  fall  upon  the  head, 

*  "  Lectures  on  Opei-ative  Siu'gery,"  p.  158. 
t  "Auuales  d'Oculistique,"  1865. 


()56  DISEASES   OF   THE  ORBIT. 

and  the  effect  is  immediate,  blood  is  effused  into  the  orbital  cellular 
tissue,  and  a  certain  degree  of  exophthalmos  may  be  produced.  As 
the  exophthalmos  increases,  the  eyelids  become  swollen,  red,  and  cedema- 
tous,  the  conjunctival  and  subconjunctival  vessels  congested,  the  move- 
ments of  the  eyeball  diminished,  and  the  sight  perhaps  more  or  less 
impaired.  The  blood-vessels  around  the  eye  are  also  sometimes  dilated 
and  tortuous.  A  bluish,  elastic,  soft  tumour  now  makes  its  appearance 
at  some  point  of  the  edge  of  the  orbit,  and  shows  distinct  pulsations, 
which  are  evident  both  to  the  eye  and  touch,  are  synchronous  with  the 
systole  of  the  heart,  and  accompanied  by  an  audible  thrill.  If  the 
ear  is  applied,  a  peculiar  humming  or  whirring  sound  is  heard,  like  the 
action  of  a  steam-engine,  threshing-machine,  or  humming-top,  and  this 
proves  a  source  of  the  greatest  distress  and  anxiety  to  the  patient.  This 
may  extend  over  a  considerable  portion  of  the  head.  In  a  case  narrated 
by  Dr.  Joseph  Bell,*  this  whirring  sound  was  audible  to  a  bystander  at 
the  distance  of  a  yard.  There  is  often  also  intense  pain  in  and  around 
the  orbit  and  over  the  corresponding  side  of  the  head.  Compression  of 
the  carotid  artery  at  once  stops  the  pulsation,  and  pressure  upon  the 
tumour  generally  causes  it  distinctly  to  diminish  in  size.  In  some 
cases,  the  appearances  of  an  aneurismal  tumour  do  not  come  on  till  some 
length  of  time  after  the  accident,  and  its  increase  is  slow  and  gradual; 
in  other  instances,  the  symptoms  supervene  immediately,  or  very  rapidly 
upon  the  injury. 

The  consecutive  diffuse  aneurism  of  the  orbit  is  frequently  preceded 
by  a  true  aneurism,  accompanied  by  a  fatty  or  atheromatous  degenera- 
tion of  the  walls  of  the  vessel,  which  thus  become  weakened.  But  the 
disease  of  the  walls  of  the  blood-vessel  may  also  be  alone  present.  Any 
sudden  strain  or  exertion  on  the  part  of  the  patient  causes  the  vessel  to 
give  way,  and  this  is  accompanied  by  a  very  marked  and  sudden  pain 
through  the  head  and  eye,  as  if  a  pistol  had  been  shot  off,  or  something 
had  given  way  within  the  head.  The  blood  flows  through  the  rent  in 
the  artery,  and,  becoming  infiltrated  in  the  surrounding  cellular  tissue, 
a  cavity,  communicating  directly  with  the  vessel,  is  formed.  Symptoms 
of  exophthalmos,  together  with  pulsation  and  a  bruit  in  the  tumoui^  and 
other  symptoms  of  aneurism,  supervene,  the  patient  at  the  same  time 
experiencing  intense  pain.  Sometimes,  the  disease  may  appear  spon- 
taneously without  the  slightest  apparent  cause,  and  without  any 
accident  or  violent  exertion.  It  has  been  frequently  met  with  in  women 
during  the  time  of  pregnancy  or  childbirth.  Compression  of  the  carotid 
causes  a  considerable  diminution  or  arrest  of  the  pulsation  and  bruit, 
but  is  sometimes  accompanied  by  severe  pain  and  distressing  symptoms 
of  fulness  in  the  head  (Gioppi).     Or  these  may  be  produced  to  a  very 

*  "  Edinburgh  Medical  Journal,"  1861,  p.  1064. 


ANEURISMS   OF   THE   ORBIT.  057 

marked  degree  by  sudden  relaxation  of  the  pressure,  whereas  a  gradual 
removal  produces  no  pain.* 

But  all  the  symptoms  of  orbital  aneurism  may  exist  without  the 
presence  of  any  such  affection  within  the  orbit ;  the  pulsating  orbital 
tumour  being  simply  due  to  some  compression  of  the  ophthalmic  vein, 
which  prevents  the  efflux  of  the  blood  from  the  orbit.  The  cause  of 
this  compression  is  frequently  the  presence  of  an  aneurism  of  the  oph- 
thalmic artery  near  its  origin,  or  of  the  internal  carotid  artery.  Thus 
Mr.  Nunneley,  in  his  valuable  and  interesting  paper  on  "  Vascular  Pro- 
trusion of  the  Eyeball,  "t  narrates,  amongst  other  cases,  that  of  a 
patient  in  whom  he  successfully  tied  the  carotid,  in  1859,  for  a  pulsating 
tumour  of  the  orbit.  In  1864  she  died,  and  on  post  mortem  examination 
the  presence  of  a  circumscribed  aneurism  of  the  ophthalmic  artery  was 
discovered,  just  at  its  origin,  of  the  size  of  a  hazel  nut.  The  trunk  and 
branches  of  the  ophthalmic  artery,  continued  forwards  into  the  orbit, 
being  of  small  size.  The  following  case  of  Mr.  Bowman's^  is  also  of 
much  interest,  as  showing  how  all  the  symptoms  of  orbital  aneurism 
may  be  simulated  without  the  existence  of  any  such  affection.  The 
patient,  a  woman,  aged  40,  noticed  severe  pain  in  the  left  temple  very 
shortly  after  a  blow  of  the  fist  on  the  left  side  of  the  head  and  temple. 
A  fortnight  afterwards,  she  felt  a  constant  rushing  sensation  on  the  same 
side  of  the  head,  like  the  beat  of  a  steam-engine,  which  increased  with 
acceleration  of  the  heart's  action.  On  her  admission  into  King's  College 
Hospital,  under  Mr.  Bowman,  the  eye  was  prominent  and  congested,  the 
pupil  dilated  but  active,  distant  sight  was  perfect,  but  she  was  unable 
to  read.  There  was  a  loud  sibilant  bruit  over  the  left  side  of  the  head, 
being  synchronous  with  the  beating  of  the  heart ;  also  distinct  pulsation 
of  the  left  eye,  apparent  to  the  touch,  and  a  loud  bruit  could  be  heard 
when  the  stethoscope  was  placed  on  the  closed  eyelids.  Mr.  Bowman 
tied  the  common  carotid,  and  the  pulsation  and  bruit,  hitherto  felt  and 
heard  over  the  front  of  the  eye,  at  once  ceased.  But  the  patient  died 
18  days  after  the  operation  from  phagedaenic  ulceration  and  haemorrhage 
from  the  wound.  On  post  mortem  examination,  no  appearance  of  an 
aneurism  could  be  discovered,  and  it  is  difficult,  as  Mr.  Hulke  says  in 
reporting  the  case  "  to  explain  the  aneurismal  symptoms  by  the  patho- 
logical appearances  which  were  those  of  phlebitis  of  the  cavernous, 
transverse,  circular,  and  petrosal  sinuses.  The  internal  carotid  may 
have  been  partially  compressed  by  the  swollen  walls  of  the  cavernous 
sinus  against  the  side  of  the  body  of  the  sphenoid  bone,  giving  rise  to 
the  bruit,  which  would  have  a  good  conducting  medium  in  the  cranial 
bones.     The  plugging  of  the  trunk  of  the  ophthalmic  vein,  where  it 

*  Dr.  Joseph  Bell,  1.  c,  p.  1065. 

t  "  Med.-Chir.  Trans.,"  vol.  48,  1865,  p.  29. 

I  "  E.  L.  O.  H.  Eep.,"  ii,  p.  6. 

2  U 


658  DISEASES   OF   THE   ORBIT. 

joins  the  cavernous  sinus,  by  obstructing  the  return  of  blood  from  the 
orbit,  accounts  for  the  protrusion  of  the  eyeball,  and  perhaps  also  for 
the  pulsation  which  was  felt  when  the  finger  was  laid  on  it,  because 
each  diastole  of  the  ophthalmic  artery  must  have  been  attended  by  a 
general  momentary  increase  of  the  whole  quantity  of  blood  in  the  orbit, 
because  its  exit  through  the  ophthalmic  vein  was  cut  off,  and  the 
resisting  bony  walls  of  the  orbit  could  permit  a  distension  in  front 
only." 

The  operation  of  ligature  of  the  common  carotid  has  proved  very 
successful  in  cases  of  aneurism  or  supposed  aneurism  of  the  orbit. 
Thus,  Dr.  Morton,  of  Pennsylvania,  has  collected  thirty  cases  in 
which  the  common  carotid  was  tied,  of  these  twenty-two  were  cured, 
three  partially  successful,  two  unsuccessful,  and  three  fatal.  Since 
then  Mr.  Zachariah  Laurence*  has  successfully  performed  the  operation, 
and  another  successful  case  is  reported  by  Dr.  BelLf 

Digital  compression  of  the  carotid  has  proved  successful  in  three 
cases,  viz.,  in  those  of  Gioppi,J  Yanzetti,§  and  Freeman. ||  In  a  case 
of  Sczokalskis's^  digital  compression  was  continued  for  fifty-six 
hours,  together  with  ice-cold  compresses  and  small  doses  of  digitalis, 
but  proved  quite  unavailing.  Ligature  of  the  common  carotid  was 
then  performed  with  perfect  success.  Digital  compression  may  be 
applied  in  such  a  manner  as  to  press  the  common  carotid  directly  back 
against  the  vertebral  column ;  but  in  this  mode  the  jugular  vein  is 
very  apt  to  be  also  compressed,  which  produces  great  congestion  of  the 
head.  It  is,  therefore,  better  to  raise  the  carotid  somewhat,  and  com- 
press it  between  the  fingers.  Relays  of  assistants  should  be  ready  to 
alternate  in  this  duty.  Sometimes,  however,  it  cannot  be  borne  for 
longer  than  four  or  five  minutes  at  a  time.  The  success  of  these  cases 
should  encourage  us  to  give  this  method  of  treatment  by  digital  com- 
pression a  fair  trial,  before  having  recourse  to  ligature  of  the  carotid, 
for  this  operation  can  always  be  performed  if  compression  fails. 

Two  cases  have  been  successfully  treated  by  styptics  ;  and  Mr.  Holmes 
mentions  a  case  of  traumatic  aneurism  cured  by  the  administration  of 
the  extract  of  ergot,  and  tincture  of  green  hellebore,  together  with 
complete  rest  and  low  diet.**     Two  cases  in  which   electrolysis  and 

*  "  Ophthalmic  Review,"  12. 

t  "Edinburgh  Medical  Jom-nal,"  1867,  Jidy. 

J  "  Annales  d'Oculistique,"  NoTember  and  December,  1858. 

§  "  Annali  Univers.,"  1858,  p.  148  ;  vide  also  "  Lancet,"  March  15,  1862. 

II  "American  Journal  of  Med.  Science,"  July,  1866. 

%  "  Kl.  Monatsbl.,"  ii,  427.  For  further  information,  and  a  tabulated  arrange- 
ment of  cases  of  aneurism  that  have  been  operated  upon,  I  would  refer  the  reader 
to  Dr.  Morton's  able  paper  in  "  Amer.  Jour,  of  Med.  Science,"  April,  1865,  and 
Zehcndcr's  article  in  "  Kl.  Monatsbl.,"  18P8,  99. 

**  "  Amer.  Jour,  of  Med.  Science,"  July,  1864. 


EFFUSION  OF  BLOOD  INTO  THE  ORBIT.         659 

injection  of  the  perchloride  of  iron  were  tried,  are  narrated  in  Zander 
and  Geissler.*  The  hitter  remedy  is,  however,  excessively  dangerous, 
for  instantaneous  death  has  been  caused  by  it  more  than  once. 


8.— EFFUSION  OF  BLOOD  INTO  THE  ORBIT. 

The  eflfusion  of  blood  into  the  orbit  is  generally  rapid,  and  can 
mostly  be  traced  to  some  direct  cause,  such  as  a  blow  or  fall  upon 
the  eye  or  head,  incised  or  punctured  wounds  of  the  orbit,  or  the 
lodgement  of  a  foreign  body  within  the  latter.  In  rarer  instances,  the 
haemorrhage  may  be  due  to  violent  exertion  or  straining,  or  may  even 
be  spontaneous  in  its  origin.  The  eye  generally  becomes  rapidly  pro- 
truded, and  its  mobility  curtailed.  Frequently  the  protrusion,  as  well 
as  the  impaii'ment  of  the  mobility  of  the  eyeball,  occur  chiefly  in  certain 
directions.  The  sight  is  more  or  less  affected,  and  this  is  chiefly  due 
to  direct  pressure  upon  the  optic  nerve  by  the  effusion,  but  in  cases  of 
injuries  to  the  head,  it  must  be  remembered  that  the  affection  of  the 
sight  may  be  dependent  upon  some  cerebral  lesion.  Thus,  consecutive 
neuro-retinitis  may  become  developed,  being  due  to  the  inflammation  of 
the  meninges. t  On  account  of  the  impairment  of  the  mobihty  of  the  eye 
there  is  also  diplopia.  The  eyelids  ai'e  often  much  swollen,  contused, 
discoloured,  and  perhaps  studded  with  ecchymoses,  which  may  also 
occur  in  the  conjunctiva  and  subconjunctival  tissue.  Moreover, 
although  the  blood  may  be  at  first  confined  to  the  posterior  portion 
of  the  orbit,  it  may  press  forward  and  become  diffused  beneath  the 
conjunctiva,  and  thus  produce  considerable  chemosis.  In  cases  of 
orbital  haemorrhage  dependent  upon  fracture  of  the  bones  of  the 
orbit,  it  has  been  supposed  that  the  presence  of  ecchymoses  in  the 
eyeUds  is  a  guide  to  the  diagnosis  of  the  seat  of  the  fracture.  Vel- 
peau  especially  insisted  upon  the  importance  of  this  symptom.  When 
ecchymosis  of  the  Hds  exists  alone  or  precedes  subconjunctival  effusion, 
it  was  supposed  to  be  indicative  of  a  fracture  of  the  margin  of  the 
orbit.  Whereas,  subconjunctival  effusion  existing  with  other  symp- 
toms of  fracture  of  the  orbit,  in  which  there  was  no  ecchymosis  of  the 
eyelids,  or  this  only  came  on  subsequently,  was  supposed  to  be  patho- 
gnomonic of  the  injury  being  situated  deeper  in,  or  at  the  bottom  of,  the 
orbit,  ^ut  absolute  reliance  cannot  be  placed  upon  these  symptoms, 
for  the  bones  of  the  orbit  may  be  fractured,  and  yet  there  may  be  not 
the  slightest  effusion  of  blood  either  under  the  conjunctiva,  or  into  the 
eyelids.  If  there  is  a  fracture  of  the  inner  or  lower  wall  of  the  orbit, 
emphysema  of  the  latter  may  also  be  produced,  and  then  the  pro- 
trusion of  the  eye  will  be  increased  when  the  nose  is  blown. 

*  Verletzungen  des  Auges,  433.  t  Vide  Mauz,  "A.  f.  O.,"  xii,  1,  1. 

2  u  2 


660  DISEASES   OF   THE   ORBIT. 

The  treatment  must  be  chiefly  directed  to  hastening  the  absorption 
of  the  blood.  Cold  compresses  and  a  firm  bandage  will  be  found  most 
serviceable.  Only  in  those  cases  in  which  the  efiusion  of  the  blood  is 
very  great,  and  causes  extreme  exophthalmos  with  very  severe  suffer- 
ing to  the  patient,  is  it  advisable  to  make  incisions,  in  order  to  permit 
the  escape  of  the  blood.  In  the  majority  of  cases,  it  is  wiser  to  permit 
it  to  be  absorbed. 

9.— EMPHYSEMA  OF  THE  ORBIT. 

Emphysema  of  the  orbit  is  generally  accompanied  by  a  similar  con- 
dition of  the  eyelids.  The  affection  may  be  produced  by  a  rupture  of 
the  ethmoidal  cells,  by  fracture  of  the  frontal  sinus,  in  which  case  the 
swelling  may  extend  to  the  forehead  and  temple,  or,  as  is  most 
frequently  the  case,  by  a  rupture  of  the  lachrymal  sac.  The  air  is 
admitted  into  the  cellular  tissue  of  the  orbit  and  eyelids,  causing  great 
protrusion  of  the  eye  and  swelling  of  the  lids,  both  subsiding  consider- 
ably when  gentle  pressure  is  applied  to  the  eyeball  and  lids.  If  the 
affection  is  due  to  a  rupture  of  the  lachrymal  sac,  the  swelling  may  be 
immediately  produced  by  the  patient's  forcibly  blowing  his  nose.  The 
emphysematous  swelHng  is  very  elastic  to  the  touch,  and  there  are 
marked  symptoms  of  crepitation. 

10.— PRESSURE  UPON  THE  ORBIT  FROM  NEIGHBOURING 

CAVITIES. 

Dilatation  of  the  cavities  in  the  vicinity  of  the  orbit  will  cause  a 
contraction  and  malformation  of  the  latter,  accompanied  by  more  or  less 
considerable  exophthalmos,  cui'tailment  of  the  mobihty  of  the  eyeball, 
and  impairment  of  vision. 

Diseases' of  the  frontal  simis*  may  produce  considerable  dilatation  of 
this  cavity,  which  then  encroaches  upon  the  orbit,  giving  rise  to  a  con- 
traction and  malformation  of  the  latter,  and  consequent  protrusion  of 
the  eyeball.  Amongst  such  affections  of  the  frontal  sinus,  must  be 
enumerated  acute  and  chronic  inflammation  of  its  lining  membrane, 
giving  rise  to  the  formation  of  a  purulent  or  muco-purulent  discharge  ; 
in  rarer  instances  polypi,  cystic  tumours,  and  entozoa  are  met  with ; 
also,  perhaps,  exostosis.  The  latter  is,  however,  according  to  Mackenzie, 
so  extremely  rare,  that  he  is  not  aware  of  a  single  recorded  case  of 
exostosis  of  the  frontal  sinus,  although  ho  happens  to  have  two  speci- 
mens in  his  own  collection. f     Of  these  diseases  of  the  frontal  sinus, 

•  Vide  Mr.  Hulke's  articles  on  Diseases  of  the  Frontal  Sinus,  "  R.  L.  O.  H. 
Eep.,"  iii,  117. 

t  Mackenzie's,  "  Diseases  of  the  Eye,"  4.th  edit.,  i,  p.  59. 


PRESSUEE  UPON  THE  ORBIT  FROM  NEIGHBOURING  CAVITIES.      661 

acute  and  clironic  inflammation,  terminating  in.  abscess,  are  the  most 
common. 

The  symptoms  presented  by  abscess  of  the  frontal  sinus  are  often 
somewhat  obscm-e,  and  may  mislead  even  an  experienced  sui-geon,  for 
they  may  very  closely  simulate  those  presented  by  an  intra-orbital 
tumour. 

The  disease  generally  presents  the  following  symptoms : — The 
patient  experiences  a  feeling  of  fulness  and  uneasiness  over  the  eye- 
brow, accompanied  by  a  dull  aching  pain,  which  is  sometimes  increased 
by  pressure  upon  this  spot,  or  by  any  exertion  or  posture  which  causes  an 
acceleration  of  the  circulation.  In  the  acute  abscess,  the  muco-purulent 
discharge  generally  perforates  the  roof  of  the  orbit,  or  makes  its  way 
into  the  nose  at  an  early  stage,  before  there  has  been  time  for  the  sinus 
to  become  much  dilated.  If  the  discharge  has  made  its  way  into  the 
orbit,  the  eyelids  become  red  and  swollen,  the  upper  lid  perhaps  droop- 
ing a  little,  and  a  small  elastic  tumour  appears  at  the  inner  and  upper 
angle  of  the  orbit.  As  the  abscess  increases  in  size,  the  eyeball  is  dis- 
placed in  a  downward  and  outward  direction,  becomes  more  and  more 
protruded,  and  its  mobility  impaired,  in  consequence  of  which,  diplopia 
manifests  itself  when  the  patient  looks  upwards.  If  the  abscess  is  not 
opened,  it  will  point  and  burst  through  the  skin  of  the  upper  eyehd, 
generally  near  its  inner  angle,  or  perhaps  lower  down,  ju^st  above  the 
tendon  of  the  orbicularis,  when  the  fistulous  opening  which  remains 
may  be  raistaken  for  inflammation  of  the  lachrymal  sac.  But  if  a 
probe  be  passed  into  the  opening,  the  sinus  will  be  found  to  extend 
in  an  upward  and  backward  direction,  perhaps  to  a  very  considerable 
distance.  Sometimes,  there  are  several  fistulous  openings.  In  a 
chronic  abscess,  the  frontal  sinus  often  becomes  very  considerably  dis- 
tended by  the  collection  of  mucus,  and  this  produces  great  exophthalmos 
and  gives  rise  to  a  marked  prominence  over  the  eyebrow.  The  pro- 
gress of  the  chronic  abscess  is  often  extremely  slow  and  protracted, 
and  accompanied  by  but  little  pain  and  discomfort  until  symptoms  of 
exophthalmos  and  diplopia  supervene.  Inflammation  and  abscess  of 
the  frontal  sinus  are,  in  the  majority  of  cases,  caused  by  blows  or  falls 
upon  this  part  of  the  face. 

As  the  symptoms  are  generally  at  the  outset  very  obscui'e,  the 
treatment  can  then  be  only  directed  to  the  alleviation  of  the  pain  or 
inflammation,  by  the  application  of  warm  poppy  fomentations.  But 
when  the  presence  of  matter  is  ascertained,  a  free  incision  should  be 
made  into  the  swelling  just  beneath  the  supra-orbital  arch,  and  the  pus 
be  thoroughly  evacuated,  the  finger  or  a  small  piece  of  sponge  being 
introduced  into  the  ca\aty  of  the  frontal  sinus  for  this  pur^pose.  The 
point  of  the  forefinger  should  then  be  inserted  into  the  dilated  siaiis  in 
order  to  ascertain  its  relation  with  the  neighbouring  cavities,  and  also 


662  DISEASES   OF   THE   ORBIT. 

the  condition  of  its  lining  membrane.  The  point  of  the  little  finger 
should  next  be  introduced  up  the  corresponding  nostril  as  high  as  the 
floor  of  the  dilated  sinus,  and  a  bistoury  should  be  passed  through 
the  opening  in  the  frontal  sinus,  and  the  lower  wall  of  the  latter,  just 
over  the  tip  of  tlie  finger  introduced  by  the  nostril,  shoidd  be  incised,  so 
that  a  free  communication  may  be  established  between  the  sinus  and  the 
nasal  cavity.  A  stout  seton,  composed  of  several  thick  silk  threads,  is 
then  to  be  passed  through  the  aperture  in  the  skin  into  the  sinus  and 
thence  through  the  nostril,  the  free  end,  projecting  through  the  latter, 
being  tied  to  that  which  projects  from  the  incision  in  the  skin,  so  that  a 
large  and  easily  moveable  loop  is  formed,  which  should  be  freely  moved 
by  the  patient  two  or  three  times  a  day,  so  as  to  keep  the  opening 
between  the  nasal  cavity  and  sinus  permanently  patent.  The  patient 
is  to  be  kept  in  bed  for  some  days  and  closely  watched.  The  seton 
should  be  worn  for  several  weeks,  or  even  longer,  but  should  be  re- 
moved if  it  gives  rise  to  much  irritation  or  to  cerebral  symptoms. 
When  the  communication  with  the  nose  has  been  permanently  esta- 
blished, the  seton  shoiild  be  removed,  and  the  opening  in  the  skin  will 
then  granulate  and  heal.  I  have  seen  several  cases  very  successfully 
treated  in  this  way  by  Mr.  Bowman. 

Enlargeme^it  of  the  maxillary  sinus,  the  nasal  cavity,  and  the  cavity 
of  the  cranium  may  also  cause  pressure  upon,  and  a  contraction  of,  the 
cavity  of  the  orbit,  accompanied  by  protrusion  of  the  eye  and  limitation 
of  its  movements.  For  interesting  cases  illustrative  of  these  difierent 
conditions,  I  must  refer  the  reader  to  Mackenzie's  "  Treatise  on  Diseases 
of  the  Bye." 


11. —WOUNDS  AND  INJURIES  OF  THE  ORBIT. 

Incised  and  punctured  wounds  of  the  orbit  should  always  be 
watched  with  care,  for  serious  symptoms  do  not  always  arise  directly 
after  the  injury,  and  may  not  manifest  themselves  till  some  time  after- 
wards. The  instrument  which  has  infiicted  the  injury  should  be 
examined,  in  order  that  we  may  ascertain  whether  a  portion  of  it  has 
not  been  broken  off",  and  perhaps  remains  lodged  within  the  orbit. 
Even  if  the  eyeball  itself  and  the  bones  of  the  orbit  have  escaped  direct 
injury,  inflammation  of  the  cellular  tissue  of  the  orbit  and  a  more  or 
less  extensive  formation  of  pus  are  very  likely  to  occur. 

Foreign  bodies,  more  especially  if  they  are  small  in  size,  such  as 
shot,  splinters  of  glass,  steel,  etc.,  may  remain  for  a  long  time  unde- 
tected within  the  orbit.  The  lodgement  of  a  foreign  body  in  the  orbit  may 


WOUNDS   AND   INJURIES   OF   THE   ORBIT.  663 

prove  dangerous  by  direct  injury  to  the  eyeball  itself,  the  optic  nerve, 
or  the  orbital  walls,  which  may  be  fractured.  Or  it  may  produce 
inflammation  of  the  cellular  tissue  of  the  orbit,  or  of  the  periosteum,  etc. 

Sometimes,  very  large  foreign  bodies  have  been  lodged  in  the  orbit 
without  the  patient  being  aware  of  their  presence.  Very  extraordinary 
cases  of  this  kind  have  been  recorded,  amongst  others,  by  Nelaton,* 
and  Mr.  R.  B.  Carter,  of  Stroud. t  In  the  latter  instance,  a  portion  of 
hat-peg  3~  inches  in  length,  had  remained  impacted  in  the  orbit  for 
fi'om  ten  to  twenty  days  without  the  patient's  being  aware  of  it.  It 
was  so  successfully  removed  by  Mr.  Clarke,  that  the  patient  recovered 
without  a  smgle  unfavourable  symptom,  the  vision  and  movements  of 
the  eye  being  unimpaired. 

Fractures  of  the  walls  of  the  orbit  are  extremely  dangerous,  more 
especially  when  the  roof  or  upper  portion  of  the  inner  wall  is  fractured, 
for  the  foreign  body  (frequently  the  stem  of  a  pointed  instrument,  as 
the  ferrule  of  an  umbrella,  etc.)  may  penetrate  the  cranium,  or  the 
splinters  of  the  fractured  bone  may  set  up  great  irritation  and  inflam- 
mation of  the  brain  and  the  meninges.  The  severe  character  of  the 
injury  and  the  presence  of  cerebral  symptoms,  may  not  show  them- 
selves for  a  day  or  two  after  the  accident. 

If  the  fracture  extends  from  the  orbit  into  the  ethmoidal  or  frontal 
cells,  there  is  generally  emphysema  of  the  orbit  and  eyelids. 

The  treatment  of  injuries  of  the  orbit  must  vary  with  their  nature. 
In  cases  of  incised  and  punctui-ed  wounds,  we  must  endeavour  to  sub- 
due the  inflammatory  reaction  by  cold  compresses,  leeches,  etc.,  and  an 
early  evacuation  of  the  pus.  Foreign  bodies  should  be  removed  as  soon 
as  possible,  except  if  they  are  of  so  small  a  size  that  they  would  be  found 
with  difiiculty,  and  their  removal  might  cause  more  disturbance  than 
their  presence. 

Before  an  operation  is  attempted  for  the  removal  of  a  foreign  body, 
the  size,  nature,  and  position  of  the  latter  should  be  ascertained  as 
accurately  as  possible  by  a  careful  examination.  If  the  foreign  body 
be  considerable  in  size,  and  situated  deeply  in  the  orbit,  so  that  it 
must  be  cut  down  upon,  the  outer  canthus  may  have  to  be  divided  in. 
order  that  the  upper  or  lower  lid  (as  the  case  may  be)  can  be  turned 
Tip  or  down.  The  conjunctiva  between  the  eyeball  and  the  lid  should 
be  divided  over  the  point  where  it  is  supposed  that  the  foreign  body  is 
situated,  and  a  probe  or  the  tip  of  the  little  finger  be  introduced  to 
ascertain  its  exact  position,  when  it  may  be  grasped  and  extracted  with 
a  pair  of  forceps.  The  incision  should  never  be  made  through  the  skin 
of  the  eyelid,  for  the  contraction  consequent  upon  the  cicatrization  of 
the  wound  may  give  rise  to  a  subsequent  ectropium.     The  lips  of  the 

*  Zander  and  Geissler,  lo.  cit.,  225.  +  "Oplith.  Rev.,"  No.  4,  p.  337. 


664  DISEASES  OF  THE  ORBIT. 

incision  at  the  outer  can  thus  are  then  to  be  united  by  two  or  three  fine 
sutures,  or  the  twisted  wire  suture. 

In  fractures  of  the  orbit  the  most  absolute  rest  must  be  enforced, 
the  patient  should  be  placed  upon  low  diet,  and  the  use  of  stimulants 
should  be  forbidden.  Cold  compresses,  and,  if  necessary,  leeches, 
should  be  applied. 

The  eyeball  may  be  dislocated  and  pushed  out  of  the  orbit,  by  a 
foreign  body,  e.g.,  a  piece  of  iron,  the  ferrule  of  an  umbrella  or  stick, 
etc.,  being  thrust  into  the  socket.  In  such  cases,  the  eye  lies  upon  the 
cheek,  protruding  far  beyond  the  lids,  which  cannot  be  closed  over  it. 
The  optic  nerve  is,  of  course  greatly  stretched,  and  vision  more  or  less 
completely  lost,  but  on  the  removal  of  the  foreign  body,  and  replace- 
ment of  the  eye,  the  sight  may  be  perfectly  restored.  The  foreign 
body  should  be  immediately  extracted,  and  the  eye  replaced.  The 
latter  is  to  be  done  by  gently,  yet  firmly  and  steadily,  pressing  the  eye- 
ball back,  which  will  cause  it  suddenly  to  spring  back  into  the  orbit, 
the  sight  being  then  generally  at  once  restored.  The  eye  should  be 
retained  in  its  position  by  a  firm  compress  bandage. 

12.— EXCISION  OF  THE  EYEBALL. 

The  modern  method  of  removing  the  eye  was  first  devised  by 
Bonnet  and  O'Ferral  in  1841,  independently  of  each  other.  Stoeber 
practised  it  in  1842,  and  Critchett  first  introduced  it  in  London  in 
1851. 

The  principal  advantages  of  this  operation  over  the  old  one  are, 
that  the  eye  is  removed  from  the  ocular  capsule  without  any  injury  to, 
or  interference  with,  the  cellular  tissue  of  the  orbit,  or  a  division  of  the 
outer  commissure  of  the  eyelids ;  that  the  muscles  are  divided  quite 
close  to  their  insertion  into  the  sclerotic,  that  nearly  the  whole  of  the 
conjunctiva  is  preserved,  and  that  only  a  few  blood-vessels  are  divided. 
Thus  there  is  but  a  moderate  amount  of  haemorrhage,  and  an  excellent 
degree  of  mobility  is  preserved  for  the  insertion  of  an  ai'tificial  eye. 

The  operation  is  best  performed  in  the  following  manner : — The 
patient  should  lie  on  a  couch,  and  a  large  sponge  should  be  placed 
beneath  the  temple  and  cheek  of  the  side  corresponding  to  the  eye 
about  to  be  removed,  so  that  the  blood  may  not  flow  down  his  neck  or 
over  his  clothes.  An  assistant  should  be  ready  with  several  smaller 
sponges,  to  wipe  away  the  blood  from  the  eye  during  the  different  steps 
of  the  operation.  The  patient  having  been  brought  thoroughly  under 
the  influence  of  chloroform,  and  the  eyelids  held  apart  by  the  stop 
speculum,  the  operator  places  himself  behind  the  patient,  and,  fixing 
the  eyeball  steadily  with  a  pair  of  forceps,  divides  the  conjunctiva  all 


EXCISION   OF   THE  EYEBALL.  665 

roTind  the  cornea  and  quite  close  to  the  latter,  with  a  pair  of  strong 
blunt-pointed  scissors  curved  on  the  flat.  He  next  incises  the  subcon- 
junctival tissue  at  one  point,  and,  passing  a  strabismus  hook  through 
this  aperture,  catches  up  one  of  the  recti  muscles,  and  divides  it  quite 
close  to  its  insertion.  The  four  recti  mxTScles  are  to  be  thus  divided  in 
succession.  When  this  has  been  done,  the  operator  presses  back  the 
upper  and  lower  eyelid,  so  as  to  make  the  eyeball  spring  forth  through 
the  small  opening  in  the  conjunctiva  and  protrude  between  the  eyelids. 
The  cut  end  of  the  tendon  of  the  external  or  internal  rectus  muscle 
being  seized  with  the  forceps,  and  the  eyeball  rolled  to  the  corresponding 
side,  the  scissors  (closed)  are  to  be  passed  along  the  posterior  surface 
of  the  globe  until  the  optic  nerve  is  reached,  when  the  blades  are  to  be 
opened  and  the  nerve  divided  quite  close  to  the  sclerotic.  The  eyeball 
should  now  be  lifted  forward  by  the  fingers,  and  any  portions  of  con- 
junctiva or  subconjunctival  tissue  which  may  adhere  to  the  globe,  as  well 
as  the  insertion  of  the  oblique  muscles,  are  to  be  divided  close  to  the 
sclerotic.  This  finishes  the  operation,  and  the  eye  will  have  been 
removed  quite  free  from  conjunctival  or  muscular  tissue,  and  present  a 
perfectly  smooth  and  polished  appearance. 

As  the  operator  stands  behind  the  patient,  it  will  be  found  most 
easy  to  divide  the  optic  nerve  of  the  right  eye  from  the  temporal  side, 
the  eye  being  at  the  same  time  rotated  inwards ;  the  left  optic  nerve, 
on  the  contrary,  is  best  divided  from  the  nasal  side.  By  so  doing,  the 
right  hand  can  be  used  for  either  eye,  and  the  operator  is  not  obliged 
to  alter  his  position. 

The  hcemorrhage  which  ensues  upon  the  division  of  the  optic  nerve 
and  ophthalmic  artery,  is  generally  soon  stopped  by  making  a  stream 
of  cold  water  from  a  sponge  (or  for  want  of  this,  from  the  narrow  spout 
of  a  small  jug)  play  upon  the  bottom  of  the  orbit,  and  it  will  not  be 
necessary  to  ligature  any  vessel.  When  the  haemorrhage  has  stopped, 
the  lips  of  the  conjunctival  aperture,  through  which  the  eye  has  been 
removed,  may  be  brought  together  by  a  fine  suture,  passed  through  the 
four  little  lappets  left  in  the  interval  of  the  recti  muscles.  The  suture, 
which  is  best  inserted  with  the  long  needle  with  a  handle  devised  for 
this  purpose  by  Mr.  Hulke,  may  then  be  firmly  tied,  so  that  the  lips 
of  the  incision  may  be  accurately  brought  together.  It  is  still  better, 
however,  to  wait  with  the  tying  of  the  suture  for  an  hour  or  two,  until 
all  hemorrhage  has  ceased.  Although  the  insertion  of  the  suture 
brings  the  edges  of  the  conjunctival  wound  very  nicely  together,  it 
should  not  be  employed  in  those  cases  in  which  the  excised  eye  is 
acutely  inflamed,  as  it  prevents  the  exit  of  inflammatory  exudations. 
After  the  completion  of  the  operation,  the  stop  speculum  should  be 
exchanged  for  a  thin  wii^e  one,  and  a  fold  of  wet  lint,  covered  by  a 
small  sponge,  should  be  inserted  into  the  orbit,  and  tied  down  firmly  with 


066  DISEASES   OF   THE   ORBIT. 

a  bandage,  so  as  to  stop  all  haemorrhage.  At  the  end  of  an  hour  or 
two,  this  may  be  removed,  and  moist  lint  applied  over  the  closed  eyelids. 
The  retraction  of  the  lids  by  the  speculum  for  an  hour  or  two  after  the 
operation  prevents  their  becoming  oedematous  and  discoloured. 

The  after  treatment  of  cases  of  excision  of  the  eye  is  generally  very 
simple.  A  cold  compress  should  be  applied  during  the  first  few  days, 
and  the  orbit  syi'inged  out  with  a  little  luke-warm  water,  to  cleanse 
away  the  discharge.  If  the  latter  should  continue  for  longer  than  a 
week  or  ten  days,  and  the  conjunctiva  looks  red  and  swollen,  a  mild 
astringent  injection  of  sulphate  of  zinc  or  alum  should  be  used  two  or 
three  times  daily.  If  symptoms  of  inflammation  of  the  cellular  tissue 
of  the  orbit  shoiTld  supervene,  warm  bread-and-water  poultices,  or 
warm  poppy  fomentations  should  be  applied,  and  the  exit  of  pus  be 
facilitated  by  a  free  incision  into  the  conjunctiva;  this  should  never  be 
neglected  if  the  lips  of  the  wound  have  been  closed  by  a  suture. 
Should  small  granulations  make  their  appearance  on  the  conjunctival 
cicatrix,  these  should  be  at  once  snipped  ofi"  with  a  pair  of  scissors. 

When  the  eye  is  excised  on  account  of  the  presence  of  an  intra- 
ocular tumour,  the  optic  nerve,  instead  of  being  divided  close  to  the 
globe,  must  be  cut  as  far  back  as  we  can  reach,  in  order  that  all  the 
diseased  portion  may,  if  possible,  be  removed.  Or  Von  Graefe's  pre- 
liminary division  of  the  optic  nerve  may  be  performed,  a  description 
of  which  will  be  found  in  the  article  on  intra-ocular  tumours  (p.  374). 
The  extirpation  of  the  eye  together  with  the  soft  parts  of  the  orbit,  as  in 
orbital  tumours,  is  a  more  severe  and  protracted  operation  than  the 
simple  excision.  The  outer  commissure  of  the  lids  must  generally  be 
divided,  in  order  to  give  more  room  for  the  extirpation  of  the  eye  and 
the  morbid  contents  of  the  orbit. 

13.— THE  APPLICATION  OF  ARTIFICIAL  EYES 
(PROTHESIS  OCULI). 

The  use  of  an  artificial  eye  should  not  be  allowed  until  five  or  six 
weeks  after  the  excision,  until  the  cicatrix  has  become  firmly  united, 
and  the  parts  are  quiet  and  free  from  all  u-ritation.  If  the  eye  has 
been  removed  on  account  of  sympathetic  irritation  of  the  other,  special 
care  must  be  taken  that  no  artificial  eye  is  worn  until  all  the  sympathetic 
symptoms  have  permanently  disappeared  for  some  months,  and  the  eye 
must  be  carefully  watched  for  some  time  afterwards,  lest  the  artificial 
eye  might  re-awaken  them.  Indeed,  the  wearing  of  an  artificial  eye  for 
too  long  a  time,  so  that  it  sets  up  great  irritation,  may  even  give  rise  to 
sympathetic  disease.* 

*  Vide  an  interesting  case  of  this  kind  recorded  by  Mr.  Lawson,  "  R.  L.  0.  H. 
Bep.,"  Ti,  2,  123. 


THE   APrLICx\TION   OF  ARTIFICIAL   EYES.  667 

At  first,  a  small  eye  should  be  worn  for  a  short  time  each  day,  and 
then,  when  the  parts  have  become  accustomed  to  it  and  there  is  a  com- 
plete absence  of  all  symptoms  of  irritation,  a  larger  one  may  be  adopted 
and  worn  for  a  longer  period,  and  at  last  the  whole  day,  but  it  should 
always  he  removed  at  night.  After  the  lapse  of  some  months,  the  internal 
surface  of  the  eye  becomes  rough,  and  as  this  is  a  ready  source  of  irri- 
tation and  discomfort  a  new  one  is  required. 

As  the  insertion  and  removal  of  the  artificial  eye  requires  some 
little  knack  and  practice,  I  subjoin  the  following  concise  and  plain  rules, 
which  are  given  to  the  patients  at  th.e  Royal  London  Ophthalmic  Hos- 
pital. 

Iiistrudions  for  Persons  wearing  an  Artificial  Eye. — It  should  be  taken 
out  every  night,  and  replaced  in  the  morning. 

To  put  the  Eye  in. — Place  the  left  hand  flat  upon  the  forehead,  with, 
the  fingers  downwards,  and  wdth  the  two  middle  fingers  raise  the  upper 
eyelid  towards  the  eyebrow ;  then  with  the  right  hand,  push  the  upper 
edge  of  the  artificial  eye  beneath  the  upper  eyelid,  which  may  be  allowed 
to  drop  upon  the  eye.  The  eye  must  now  be  supported  with  the  middle 
fingers  of  the  left  hand,  whilst  tlie  lower  eyelid  is  raised  over  its  lower 
edge  with  the  right  hand. 

To  taJie  the  Eye  out. — The  lower  eyelid  must  be  drawn  downwards 
with  the  middle  finger  of  the  left  hand,  and  then  with  the  right  hand 
the  end  of  a  small  bodkin  must  be  put  beneath  the  lower  edge  of  the 
artificial  eye,  which  must  be  raised  gently  forward  over  the  lower  eyelid, 
when  it  will  readily  drop  out ;  at  this  time  care  must  be  taken  that  the 
eye  does  not  fall  on  the  ground  or  other  hard  place,  as  it  is  very  brittle, 
and  might  easily  be  broken  by  a  fall.* 

After  it  has  been  worn  daily  for  six  months,  the  polished  surface  of 
the  artificial  eye  becomes  rough ;  when  this  happens,  it  should  be  re- 
placed by  a  new  one ;  for,  unless  this  is  done,  uneasiness  and  inflam- 
mation may  result. 

•  In  order  to  avoid  this  accident,  the  patient  should  stoop  oyer  a  cushion  or 
handkerchief  placed  on  a  table,  or  over  a  bed. 


Chapter  XVTT. 
DISEASES  OF  THE  EYELIDS. 


1.— (EDEMA  OF  THE  EYELIDS,  ETC. 

(Edema  of  the  lids  very  frequently  accompanies  (as  we  have  seen)  tlie 
severer  forms  of  inflammation  of  the  conjunctiva,  cornea,  and  iris.  It 
may,  however,  be  also  dependent  upon  some  disturbance  of  the  general 
health,  more  especially  in  feeble  and  delicate  persons.  It  is  often  due 
to  an  affection  of  the  heart  or  kidneys,  and  should,  therefore,  always 
arouse  our  suspicions,  and  lead  us  to  examine  as  to  the  presence  of 
general  dropsy,  and  of  albumen  in  the  urine.  The  degree  of  cedematous 
swelling  of  the  lids  is  subject  to  much  variation.  If  it  be  due  to  con- 
stitutional causes,  it  is  often  but  inconsiderable  in  degree,  giving  rise 
only  to  a  little  puffiness  and  fulness  of  the  lid,  which  is  generally 
greatest  in  the  morning,  and  diminishes  during  the  day.  Some- 
times, the  puffiness  is  principally  confined  to  the  lower  lid,  forming  a 
little  pouch  or  sack,  which  is  very  unsightly  if  it  be  considerable  in 
size  and  if  the  subcutaneous  veins  are  dilated,  as  the  swelling  then 
assumes  a  dusky,  bluish  tint.  The  swelling  produced  by  oedema  is 
smooth,  pale,  soft,  and  semi-transparent,  and  it  is  easily  pitted  with  the 
point  of  the  finger,  the  mark  remaining  for  a  little  time. 

If  the  oedema  is  due  to  constitutional  causes,  the  treatment  must  be 
chiefly  directed  to  their  alleviation,  when  the  swelHng  of  the  hd  will 
soon  subside.  Where  the  pufiiness  of  the  lids  occurs  spontaneously  in 
persons  of  a  feeble,  delicate  habit,  tonics  should  be  administered,  a,nd 
the  general  health  attended  to.  A  compress  bandage  should  be 
applied,  and  I  have  also  found  benefit  from  the  use  of  warm  aromatic 
bags  (containing  camomile  flowers,  camphor,  etc.)  tied  firmly  over 
the  eye.  If  the  oedema  is  very  obstinate  and  unsightly,  a  small  hori- 
zontal fold  of  skin  may  be  excised.  Where  this  condition  is  dependent 
upon  some  other  disease  of  the  eye,  this  must  be  treated,  and  when  it 
is  alleviated,  the  puffiness  will  soon  disappear. 

Emphysema  of  the  lids  is  due  to  the  admission  of  air  into  the  areolar 
tissue,  and  is  generally  caused  by  a  fracture  of  the  nasal  bones,  or  of 


INFLAMMATION   OF   THE  EYELIDS,   ETC.  669 

the  frontal  or  ethmoidal  cells,  and  rupture  of  the  mucous  membrane ; 
though  generally  produced  by  severe  blows  or  falls,  it  may  arise  after 
blowing  the  nose  very  forcibly.  The  swelling  of  the  lid  is  tense  and 
elastic,  and  there  is  distinct  crepitation  on  pressure ;  the  colour  of  the 
skin  is,  however,  unchanged.  The  treatment  consists  in  the  application 
of  a  compress  bandage,  with  the  use  of  a  mildly  stimulating  lotion. 

In  erythema  (hypercemia)  of  the  eijellds  the  skin  is  very  much  red- 
dened, and  presents  a  bright  scarlet  flush,  which  temporarily  disappears 
upon  pressure.  There  is,  however,  but  very  little,  if  any,  swelhng  of 
the  lid,  and  no  pain,  although  the  patient  complains  of  a  great  sensa- 
tion of  heat.  The  redness  generally  extends  somewhat  on  to  the  cheek, 
and  the  palpebral  and  ocular  conjunctiva  may  likewise  be  injected. 
The  veins  of  the  skin  are  also  sometimes  dilated.  This  afiection  is 
not  unfrequently  due  to  prolonged  exposure  to  very  bright  sunlight  or 
intense  heat,  and  is  also  met  with  in  persons  suffering  from  some 
irregularity  of  the  general  circulation.  Compresses,  soaked  in  cold 
water  or  in  goulard  lotion,  should  be  frequently  applied  ;  and  a  solu- 
tion of  nitrate  of  silver  (gr.  iv,  ad.  ^j)  may  be  painted  over  the  outside 
of  the  lids.  If  there  is  much  vascularity  of  the  conjunctiva,  and  a 
slight  muco-purulent  discharge,  a  weak  collyi'ium  of  sulphate  of  zinc 
or  alum  should  be  prescribed. 

A  peculiar  bluish  discolouration  of  the  eyelids  (more  especially  the 
lower  one)  is  occasionally  observed  in  persons  of  feeble  health,  and  of  a 
very  transparent  and  delicate  complexion.  This  dark  tint  is  especially 
conspicuous  beneath  the  lower  lid,  producing  a  dark  blue,  semicircular 
ring.  This  appearance  is  due  to  a  dilatation  of  the  subcutaneous  veins, 
which  are  the  more  conspicuous  on  account  of  the  delicacy  of  the  skin. 
It  is  often  difficult  to  cure  this  discolouration,  more  especially  if  a 
certain  degree  of  oedema  of  the  lid  co-exists.  I  have  found  the  most 
benefit  from  the  use  of  a  solution  of  Tannin  (gT.  iv — viii,  to.  3J  of  water), 
which  is  to  be  painted  frequently  over  the  outside  of  the  eyelids.  When 
this  has  been  employed  for  some  little  time,  a  solution  of  acetate  of 
lead  or  of  nitrate  of  silver  should  be  substituted.  Care  must,  however, 
be  taken  that  the  nitrate  of  silver  does  not  discolour  the  latter,  which  is 
especially  apt  to  happen  at  the  points  where  the  latter  is  a  little  wrinkled. 
The  general  health  should  at  the  same  time  be  attended  to,  irregularities 
in  the  circulation  or  the  digestive  functions  be  rectified,  and  abstinence 
from  every  form  of  dissipation  strictly  enforced. 

2.— INFLAMMATION  OF  THE  EYELIDS,  ETC. 

In  the  acute  phlegmoiwtts  inflammation  (abscess)  of  the  eyelids,  there 
is  great  redness,  heat,  and  swelling  of  the  lids,  which  are  also  acutely 
sensitive  to  the  touch.    The  skin  is  greatly  reddened,  and,  as  the  disease 


670  DISEASES  OP   THE  EYELIDS. 

advances,  it  assumes  a  darker  and  more  dusky  hue.  The  conjunctiva 
is  also  injected,  and  there  is  often  a  considerable  degree  of  chemosis. 
The  swelling  is  firm  and  hard  and  not  oedematous ;  it  often  extends 
over  the  eyebrow  and  cheek,  and  may  became  so  considerable  that  the 
upper  lid  is  swollen  up  to  the  size  of  a  pigeon's  egg,  or  even  larger. 
This  hardness  is  at  first  especially  conspicuous  at  one  point,  which 
feels  like  a  little,  firm,  circumscribed  nodule ;  this  increases  more  and 
m.ore  in  size,  then  the  hardness  gradually  yields,  the  swelling  becomes 
softer,  more  doughy,  and  there  is  a  distinct  sense  of  fluctuation.  The 
skin  becomes  thinned  and  yellowishly  discoloured  at  one  point,  gives 
way,  and  a  large  quantity  of  thick  creamy  pus  escapes.  In  rarer 
instances,  the  perforation  occurs  through  the  conjunctiva.  When  the 
abscess  forms  at  the  inner  angle  of  the  eye,  near  the  lachrymal  sac,  it 
has  been  termed  anchylops,  and  may  then  be  mistaken  for  acute  inflam- 
mation of  the  sac.  If  it  perforates  at  the  inner  canthus,  it  is  called 
cegilops.  It  generally,  however,  occurs  in  the  upper  lid,  which,  on 
account  of  the  swelling,  hangs  immoveably  down,  so  that  the  pal- 
pebral aperture  is  quite  closed.  The  pain  is  mostly  very  great,  and 
of  a  violently  throbbing  character,  extending  over  the  correspond- 
ing side  of  the  head  and  face.  There  is  often  also  much  constitu- 
tional distui'bance  and  feverishness.  The  course  of  the  disease  may, 
however,  be  more  chronic,  and  all  the  inflammatory  symptoms  be  sub- 
acute in  character.  Abscess  of  the  eyelid  is  almost  always  of  traumatic 
origin,  being  produced  by  wounds  or  blows  upon  the  eye.  It  may, 
however,  occur  spontaneously,  or  supervene  upon  severe  inflammation 
of  the  conjunctiva,  or  erysipelas  of  the  eyelids. 

If  the  disease  is  seen  at  the  very  outset,  we  should  endeavour  to 
produce  the  resolution  of  the  inflammatory  swelling  by  the  application 
of  cold  (iced)  compresses,  leeches,  etc.  But  if  we  cannot  succeed  in 
this,  hot  poultices  or  sedative  fomentations  should  be  applied,  in  order 
to  accelerate  the  formation  of  pus,  and  as  soon  as  fluctuation  is  felt,  a 
free  incision  should  be  made  into  the  swelling  parallel  to  the  edge  of  the 
lid,  so  as  to  give  ready  exit  to  the  discharge.  For  if  this  is  not  done, 
but  the  abscess  is  allowed  to  perforate  spontaneously,  the  sufierings  of 
the  patient  are  not  only  greatly  aggravated  and  prolonged,  but  the 
opening  will  be  ragged  and  insufiicient,  and  by  the  contraction  of  the 
cavity  of  the  abscess,  will  tend  to  produce  ectropium.  If  perforation 
has  already  occurred,  the  opening  should  be  enlarged  if  it  is  insufficient 
for  the  free  discharge  of  matter ;  and  if  several  apertures  exist  close 
together,  they  should  be  laid  open  into  one  large  wound.  After  the 
escape  of  the  pus,  warm  poultices  should  be  applied,  and  subsequently 
warm  water  dressing  and  a  compress  bandage,  so  as  to  keep  the  lid  in 
position  and  the  walls  of  the  abscess  in  contact,  and  thus  hasten  the 
union.    A  generous  diet  and  tonics  should  be  prescribed.    Any  eversion 


INFLAMMATION   OF   THE  EYELIDS,   ETC.  671 

or  malposition  of  the  eyelid  or  puncta  must  be  treated  at  a  subsequent 
period. 

In  Erysipelas  of  the  lids  the  swelling  is  not  firm,  hard,  and  of  a  dusky- 
red  tint,  but  oedematous,  softer,  and  of  a  more  rosy,  semi-transparent 
hue,  the  blush  disappearing  on  pressure.  The  cuticle  is  frequently 
elevated  in  the  form  of  small  blisters  by  an  efiusion  of  serum.  The 
swelling  of  the  lid  is  often  very  considerable,  and  extends  over  the  eye- 
brow and  down  the  cheek ;  the  conjunctiva  is  injected,  and  there  is 
more  or  less  chemosis.  There  is  likewise  much  constitutional  distur- 
bance ;  the  patient  is  feverish,  his  tongue  foul  and  loaded,  and  he  is 
often  extremely  weak  and  feeble.  The  pain  is  generally  not  very  great 
nor  of  a  throbbing  or  pulsating  character.  If  pus  is  formed,  the 
swelling  assumes  greater  firmness,  the  skin  becomes  more  tense  and 
of  a  livid,  dusky-red  tint,  and  the  pain,  heat,  and  throbbing  increase  in 
severity.  The  swelhng  becomes  softer,  there  is  a  distinct  feeling  of 
fluctuation,  and  then,  if  left  to  itself,  the  abscess  points  and  perforates. 
The  matter  may  extend  freely  into  the  connective  tissue,  and  give  rise 
to  extensive  sloughs.  But  erysipelas  may  pi'oduce  much  more  serious 
complications,  for  the  inflammation  may  extend  to  the  cellular 
tissue  of  the  orbit,  giving  rise  to  abscess  within  the  latter  and  great 
exophthalmos,  followed  pei'haps  by  sloughing  of  the  cornea  and  loss  of 
the  eye  ;  or,  the  inflammation  may  extend  backwards  from  the  orbit, 
along  the  optic  nerve  to  the  brain,  and  set  up  meningitis  ;  or,  again,  the 
erysipelatous  inflammation  may  also  become  diffuse,  and  extend  to  the 
face.  The  purulent  matter,  as  Mackenzie  points  out,  may  likewise 
make  its  way  into  the  lachrymal  sac,  which  becomes  filled  with  pus  from 
without ;  in  the  production  of  which,  its  lining  membrane  has  no  share. 

Erysipelas  of  the  eyelids  may  be  spontaneous  in  origin,  being  caused 
by  exposure  to  cold  and  wet,  more  especially  if  the  patient  is  already  in 
feeble  and  delicate  health  from  want  or  dissipation.  It  is  often,  how- 
ever, of  traumatic  origin,  being  due  to  injuries,  wounds,  etc.,  of  the 
lids.  Our  fii'st  object  in  the  treatment  must  be  to  strengthen  the 
patient.  If  the  stomach  is  much  deranged,  the  tongue  loaded,  the 
breath  foetid,  a  brisk  purgative  or  an  emetic  should  be  at  once  adminis- 
tered. Then  tonics  should  be  given,  more  especially  the  tincture  of 
steel,  or  preparations  of  steel  and  quinine.  The  diet  must  be  generous, 
and  stimulants,  particularly  port  wine  and  brandy,  should  be  freely 
administered.  Warm  poppy  or  laudanum  fomentations  should  be  applied 
to  the  lids,  or  they  may  be  painted  with  collodion.  If  pus  is  forming, 
a  free  incision  must  be  made  at  once,  in  order  to  permit  of  its  ready 
escape.  If  the  chemosis  is  very  considerable  and  firm,  so  that  it  presses 
upon  the  vessels  which  supply  the  cornea,  and  thus  endangers  the  nutri- 
tion of  the  latter,  the  chemotic  swelling  should  be  incised  at  difi'erent 
points  ;  but  if  the  pressure  of  the  swollen  lids  is  threatening  this  danger. 


672  DISEASES  OF   THE  EYELIDS. 

the  outer  cantlius  should  be  divided.  When  the  erysipelatous  inflam- 
mation has  extended  to  the  orbital  cellular  tissue,  and  the  eye  is  pro- 
truded from  a  collection  of  pus  or  efiusion  into  the  orbit,  a  free  and 
deep  incision  should  be  made  so  as  to  evacuate  it. 

Cases  of  anthrax  (carbuncle)  of  the  lids  generally  occur  in  elderly 
persons  of  feeble  health.  The  inflammatory  swelling  is  of  a  dusky,  livid- 
red,  and  firm  and  circumscribed,  and  there  is  a  great  tendency  to 
sloughing.  Vesicles  form  on  the  lid  and  burst,  discharging  sanious 
matter  ;  the  skin  and  areolar  tissue  become  black  and  gangrenous,  and, 
sloughing  out,  leave  a  more  or  less  deep  cavity,  which  then  granu- 
lates and  cicatrizes.  A  crucial  incision  should  be  made  into  the  swell- 
ing at  an  early  stage,  so  as  to  allow  the  escape  of  matter,  and  facilitate 
the  separation  of  the  slough,  and  warm  poultices  should  then  be  applied. 
The  patient's  strength  must  be  sustained  by  a  liberal  administration  of 
brandy,  wine,  tonics,  and  a  good  diet.  If  the  pain  is  great,  opium  must 
be  given,  either  internally,  or  by  the  subcutaneous  injection. 

Malignant  pustule  of  the  lids  is  said  to  be  somewhat  common  in 
certain  parts  of  France  and  of  the  continent,  but  I  have  never  heard  of 
its  having  been  met  with  in  England  in  its  true  type.  According  to 
Mackenzie,  it  is  characterised  by  the  formation  of  a  vesicle  filled  with 
bloody  serum,  which  is  accompanied  by  a  great  and  firm  swelling  of 
the  lids,  the  skin  of  which  is  dusky  and  red.  The  base  of  the  pustule 
is  hard  and  nodular,  and  soon  becomes  sloughed,  thje  gangrene  spreading 
wdth  great  rapidity.  There  is  severe  constitutional  disturbance,  much 
fever,  and  intense  pain.  The  disease  is  almost  always  produced  by  con- 
tact with  decomposing  carcases  of  cattle,  or  with  animals  sufiering  from 
farcy  ;  hence  it  is  most  frequently  met  with  amongst  tanners,  butchers, 
drovers,  etc.  It  is  so  extremely  dangerous  that  it  may  prove  fatal 
within  24  hours  of  the  outset,  the  inflammation  extending  to  the  head 
and  neck,  and  the  eye  being  either  destroyed  at  the  time,  or  subsequently 
from  exposure.  Mackenzie  states  that  the  best  treatment  is  a  deep 
crucial  incision  of  the  swelling,  followed  by  the  immediate  application 
of  the  actual  cautery.  Tonics  and  stimulants  should  be  very  freely 
administered. 


3.— SYPHILITIC  AND  EXANTHEMATOUS  AFFECTIONS   OP 

THE  EYELIDS. 

Syphilitic  ulceration  of  the  eyelid  generally  commences  at  its  free 
edge,  along  which  it  rapidly  spreads,  more  especially  towards  the  skin, 
showing  a  greater  tendency  to  extend  in  this  direction  than  inwards  to- 
wards the  conjunctiva.  The  eyelid  is  much  inflamed  and  swollen  in  the 
vicinity  of  the  ulcer,  and  of  a  dusky,  livid  hue.     The  swelling  is  firm 


SYPHILITIC   AND   EXANTHEMATOUS  AFFECTIONS.  ()73 

and  hard,  and  feels  nodulated.  The  nicer  has  a  hard,  cartilagincous 
base,  its  edges  are  irregular,  and  its  bottom  presents  a  peculiar  dirty 
and  lardaceous  appearance.  The  whole  surface  of  the  lid  is  often 
swollen  and  indurated,  and  of  a  dusky-red  tint,  the  inflammation 
extending  generally  to  the  conjunctiva,  and  being  accompanied  by  a 
muco-purulent  discharge.  If  the  disease  is  not  recognised  and  pi'o- 
perly  treated,  the  ulcer  will  rapidly  spread,  become  deeply  notched, 
and  perhaps  soon  eat  its  way  through  the  whole  substance  of  the 
lid,  destroying  skin,  cartilage,  and  conjunctiva.  Indeed  its  ravages 
may  be  so  great,  that  the  whole  of  the  eyelid  may  become  destroyed, 
and  the  disease  even  extend  to  the  other  lid.  In  rarer  instances,  the 
ulcer  may  occupy  the  internal  surface  of  the  eyelid,  and  spread  over  a 
considerable  portion  of  the  palpebral  conjunctiva  without  appearing 
externally.  If  the  ulcer  is  situated  at  the  inner  canthus,  or  the  inner 
edge  of  the  lower  lid  in  the  vicinity  of  the  lachrymal  sac,  it  may  be 
mistaken  for  a  fistula  of  the  latter ;  indeed  it  may  penetrate  into  the 
sac.  It  is  often  somewhat  difficult  to  determine  with  certainty  the  true 
nature  of  the  disease,  or  to  make  the  differential  diagnosis  between  the 
sy|:)hilitic  ulcer  and  the  different  forms  of  lupus  and  epithelioma.  The 
syphilitic  character  of  the  ulceration  must,  however,  be  suspected,  if  it 
proves  very  obstinate,  and  instead  of  yielding  to  the  usual  remedies, 
gets  worse  and  spreads  more  and  more.  We  must  then  carefully  and 
searchingly  inquire  into  the  history  of  the  case,  and  ascertain  whether 
any  other  symptoms  of  syphilis  are  present,  such  as  eruptions  of  the 
skin,  ulceration  of  the  tkroat,  etc.,  or  whether  there  has  been  any 
chance  of  direct  contagion.  For  although  these  ulcers  are  almost 
always  secondary,  a  primary  hard  chancre  of  the  Hd  may  be  met  with. 
The  softer  variety  appears,  however,  to  be  of  rare  occurrence.  The 
ulceration  may  also  extend  to  the  eyelids  from  the  neighboui'ing  parts, 
such  as  the  nose,  etc.  The  treatment  must  consist  in  bringing  the 
patient  as  rapidly  as  possible  under  the  influence  of  mercury,  either  by 
inunction  or  mercurial  baths ;  and  the  system  should  be  kept  sHghtly 
under  its  action  for  some  time,  otherwise  a  relapse  may  occur,  or  the 
ulcer  retui^n.  The  latter  should  be  freely  touched  with  caustic,  and 
when  it  is  beginning  to  heal,  the  red  precipitate  ointment,  or  the  black 
wash,  should  be  applied,  in  order  to  accelerate  the  cicatrization.  If  the 
ulceration  proves  very  obstinate,  and  resists  the  action  of  mercury, 
much  advantage  is  often  experienced  fi'om  a  course  of  Zittman's  decoc- 
tion, as  this  is  accompanied  by  a  very  free  action  of  the  skin.  If  this 
be  inapplicable,  warm  baths  should  be  prescribed  for  the  same  pur- 
pose. 

In  infants,  the  existence  of  congenital  syphilis  generally  manifests 
itself  by  the  appearance  of  papular  or  pustular  eruptions  on  the  face, 
hands,  and  around  the  anus.     The  eyelids  are  inflamed  and  swollen, 

2  X 


674  DISEASES   OF   THE   EYELIDS. 

there  is  a  purulent  discharge,  and,  in  very  weak  and  feeble  children, 
there  is  much  danger  of  sloughing  of  the  cornea  and  loss  of  the 
eye.  Small  doses  of  calomel  and  opium  should  he  administered,  and 
an  astringent  collyrium,  or  the  red  precipitate  ointment  should  be 
applied. 

I  have  already  mentioned,  when  treating  of  the  exanthematous 
affections  of  the  conjunctiva,  that  the  eyelids  are  also  very  prone  to 
suffer  during  the  exanthemata,  more  especially  in  small-pox.  Eczema 
of  the  lids  occurs  very  frequently  in  conjunction  with  eczema  of  the 
face.  It  is  also  due  to  severe  and  protracted  inflammation  of  the  con- 
junctiva or  cornea,  more  especially  phlyctenular  ophthalmia,  and  is 
caused  by  the  irritation  of  the  constant  discharge,  and  of  the  hot 
scalding  tears  flowing  over  the  edge  of  the  lid  and  down  the  cheek. 
The  proper  mode  of  treatment  is  described  at  p.  Q7. 

4— INFLAMMATION  OF  THE  EDGES  OF  THE  EYELIDS 
(TINEA  TARSI,  OPHTHALMIA  TARSI,  BLEPHARITIS 
MARGIN ALIS),  ETC. 

In  the  mildest  form  of  the  disease,  we  notice  only  a  hyperaemic 
condition  of  the  edges  of  the  lids,  which  look  angry,  red,  and  sore. 
There  is  at  the  same  time  a  feeling  of  heat  and  itching  in  the  eyes, 
which  becomes  aggravated  by  exposure  to  very  bright  light,  a  smoky 
atmosphere,  or  by  long  continued  use  of  the  eyes  at  fine  work.  On 
awaking  in  the  morning,  the  patient  notices  that  the  lids  are  somewhat 
glued  together,  and  that  small  crusts  form  upon  and  clog  the  lashes, 
which  are  perhaps  stuck  together  into  little  bundles  by  the  hardening 
and  drying  of  the  discharge.  The  edges  of  the  lids  now  become  some- 
what thickened  and  hypertrophied,  and  appear  red,  glazed,  and  shining. 
The  discharge  is  also  more  copious  and  thicker,  and  the  crusts  more 
firm  and  consistent.  If  the  disease  advances,  small  white  pustules  are 
formed  here  and  there  at  the  roots  of  the  lashes,  which  project  through 
the  pustules,  or  the  latter  may  be  situated  between  the  cilia.  These 
little  pustules  become  excoriated,  and  exude  a  yellowish  muco-pui'ulent 
discharge,  and  readily  bleed  if  the  edge  of  the  lid  is  rubbed,  or  the 
crusts  are  roughly  removed.  The '  margin  of  the  lid  becomes  more 
and  more  inflamed,  swollen,  and  irregularly  notched,  and  the  pustules 
may  invade  its  whole  extent,  so  that  it  looks  quite  raw  and  ulcerated 
when  the  crusts  have  been  removed.  When  the  whole  substance  of 
the  lid  along  the  margin  is  thickened  and  hardened,  it  is  termed 
tylosis.  The  conjunctiva  generally  participates  more  or  less  in  the 
inflammation,  and  this,  together  with  the  inflamed  condition  and 
altered  secretion  of  the  Meibomian  glands,  causes  a  sensation  of  sand 
and  grit  in  the  eyes,  which  feel,  moreover,  hot,  dry,  and  very  itchy. 


INFLxVMMATION   OF   THE   EDGES  OF   THE   EYELIDS.  675 

This  itchiness  is  especially  mai'ked,  if  the  lid  and  cheeks  become 
excoriated  and  inflamed.  If  conjunctivitis  supervenes,  there  is  of 
course  an  increase  in  the  discharge,  which  now  assumes  a  muco- 
purulent character.  In  the  severer  cases  of  blepharitis  marginalis, 
suppuration  of  the  hair  follicles  takes  place,  and  the  pustules  which 
form  at  the  base  of  the  cilia  may  attain  a  considerable  size,  and,  on 
giving  way  or  being  pressed,  they  exude  a  thick  muco-puralent  dis- 
charge, which  dries  upon  the  edge  of  the  lid  in  the  form  of  thick  firm 
crusts,  beneath  which  the  margin  of  the  lid  is  ulcerated,  and  perhaps 
deeply  notched  and  indented.  The  lashes  become  loose,  and  are  shed ; 
either  falling  out,  or  remaining  glued  to  the  crusts.  For  some  time, 
new  lashes  are  formed,  but  they  ai-e  not  of  normal  strength  or  growth, 
but  are  weak,  crooked,  and  stunted ;  but  if  the  disease  runs  a  very 
protracted  course,  and  is  severe  in  character,  the  lashes  cease  to  grow, 
and  a  more  or  less  considerable  portion  of  the  lid  is  completely  deprived 
of  them  (madarosis),  or,  at  best,  a  few,  thin,  straggling  cilia  are  scat- 
tered sparsely  along  its  margin.  The  position  of  the  lashes  often  un- 
dergoes a  considerable  change,  so  that  they  become  inverted,  crooked, 
and  stunted  (trichiasis),  or  a  double  row  of  cilia  (distichiasis)  may  be 
formed,  either  along  the  greater  portion  of  the  lid,  or  chiefly  at  one 
point.  There  is  also  much  danger  that  the  cicatrization  of  the  ulcers 
should  lead  to  a  closure  and  obhteration  of  the  Meibomian  apertures, 
so  that  these  become  skinned  over ;  the  secretion  from  the  glands  is 
thus  blocked  up,  and  on  pressing  the  edge  of  the  lid  no  discharge 
exudes.  This  condition,  and  the  inflammation  of  the  Meibomian  glands 
which  often  supervenes,  aggravates  still  more  the  intensity  and  ob- 
stinacy of  the  disease.  Indeed,  when  the  apertures  of  the  greater 
number  of  the  Meibomian  follicles  are  obliterated,  the  case  may  be 
considered  incurable,  and  only  capable  of  alleviation.  Whereas,  if 
these  ducts  are  still  open,  a  cure  may  with  perseverance  and  care  be 
looked  upon  as  certain,  although  many  months  may  elapse  before  it 
can  be  attained.  On  account  of  the  thickening  and  hypertrophy  of 
the  edge  of  the  lid,  this  gradually  shows  a  tendency  to  become  some- 
what everted,  and  now  the  lachrymal  punctum,  instead  of  being  turned 
in  towards  the  eyeball,  becomes  erect  or  even  everted,  and  the  tears 
which  can  no  longer  enter  it,  flow  over  the  edge  of  the  lid,  and  thus 
tend  still  more  to  maintain  or  aggravate  its  inflammation.  Moreover, 
the  latter  may  extend  to  the  puncta  and  canaliculi,  and  cause  their 
obhteration.  The  inner  edge  of  the  hd  loses  its  angularity,  becomes 
rounded  ofl",  smooth,  hardened,  and  cuticular  in  character.  The 
contraction  of  the  skin  which  ensues  upon  the  cicatrization  of  the 
excoriated  lids  and  cheek,  moreover,  increases  this  tendency  to  ectro- 
pium,  so  that  even  a  considerable  degree  of  lagophthalmos  may  be 
produced. 

2x2 


676  DISEASES   OP   THE   EYELIDS. 

BlepTiaritis  marginalis  is  frequently  produced  by  the  various  forms 
of  conjunctivitis  or  corneitis,  more   especially  if  the  latter  are  accom- 
panied by  a  great  discharge  of  hot   scalding  tears,  which  constantly 
moisten  and  excoriate  the  edges  of  the  lids.      But  it  occurs  also  as  a 
primary  disease,  and  is  then  generally  due   to  prolonged   exposure  to 
wind,    cold,  bt-ight  glare,   or  to  an  impure   smoky  atmosphere.      Its 
intensity  is  much  aggravated  by  dirt  and  want,  and  it  is,  therefore,  most 
frequently  met  with  amongst  the  poorer  classes,  and  especially  amongst 
those  nationalities  in  which  habits  of  cleanliness  do   not  prevail.     It 
occurs  most  frequently  amongst  children,  but  it  is  also  met  with  in 
adults,   and  is  especially  prone  to  attack  persons  of  a  delicate,  feeble, 
and   scrofulous    constitution,  or  who   suffer   from  impairment  of  the 
digestion ;    in  such,   it  proves  especially  obstinate    and   apt  to  recur. 
Dr.  McCall  Anderson  considers  that  this  disease  is  neither  more  nor 
less  than  a  pustular  eczema  (impetigo)  attacking  the  edges  of  the  lids.* 
In  the  treatment  of  this  disease,  the  greatest  attention  must  be  paid 
to  the  most  scrupulous  cleanliness.      In  mild  cases,  the  eye  should  be 
frequently  washed  with  tepid  water,  or  warm  milk  and  water,  so  as  to 
remove  the  crusts  from  the  lashes,  and  when  this  has  been  done,  a  little 
of  the  weak  nitrate  of  mercury  ointment  should  be  applied  to  the  roots 
of  the  lashes  with  a  fine  camel's  hair  brush.     If  this  proves  too  irritating, 
we  should  diminish  the  strength  of  this  ointment  by  an  admixture  of 
one  or  two  parts  of  lard.     If  the  crusts  are  thick  and  firm,  and  the 
edges  of  the  hds  very  swollen  and  red,  m.ere  ablution  with  warm  water 
will  not  suffice,  but  compresses,  steeped  in  hot  water,  should  be  applied 
for  ten  or  twenty  minutes,  and  frequently  changed  during  this  period. 
This  should  be  repeated  three  or  four  times   a  day,  or  hot  bread  and 
water,  or  linseed  meal  poultices  may  be  applied  instead  of  the  com- 
presses.    This  will  greatly  alleviate  the  inflammation,  and  the  crusts 
will  be  so  thoroughly  soaked  and  softened,  that  they  will  either  become 
detached  spontaneously^  or  can  be  removed  without  difficulty  or  injury 
to  the  lid.     The  hot   compresses  or  poultices  will  be  found  especially 
useful  in  the  morning,  when  the   crusts  are  thick,  and  the  lids  firmly 
glued  together  by  the  nocturnal  discharge.     After  the  removal  of  the 
crusts,  the  lids  may  be  bathed  with  tepid  water,  and  then  some  astrin- 
gent  ointment    or   lotion  should    be  applied.      Before    doing  so,  any 
diseased  or  stunted  eyelashes  should  be  extracted  with  the  cilia  forceps, 
as  this  favours  the  growth  of  the  new  ones,  and  renders  the  application 
of  the  topical  remedy  more  easy.     Indeed,  if  the  disease  is  severe  and 
implicates  the  greater  portion  of  the  lid,  it  will  be  well  to  remove  the 
greater  part  of  the  lashes,  or,  as  suggested  by  Mr.  Streatfeild,  to  cut 
them  down  quite  close  to  the  margin.     A  great  number  of  ointments 

*  "  A  practical  Ti-eatise  upou  Eczema,"  by  Dr.  McCall  Anderson,  p.  107. 


INFLAMMATION   OF   THE  EDGES   OF   THE   EYELIDS.  G77 

and  lotions  have  been  recommended  for  this  disease,  and  in  very 
chronic  and  obstinate  cases  it  is  advisable  occasionally  to  change  the 
remedy. 

In  the  milder  forms,  the  application,  night  and  morning,  of  the 
weak  nitrate  of  mercury,  or  the  red  or  white  precipitate  ointment  will 
suffice. 

If  the  edge  of  the  lid  is  much  excoriated,  a  solution  of  nitrate  of 
silver  (gr.  v — x  ad  5J.)  should  be  lightly  painted  over  it  every  day;  or 
pledgets  of  lint,  dipped  in  a  weaker  solution  of  nitrate  of  silver  or  of 
sulphate  of  zinc,  should  be  periodically  ajiplied.  If  small  pustules  or 
ulcers  have  fonned,  these  should  be  touched  with  a  finely  pointed  crayon 
of  sulphate  of  copper  or  the  mitigated  nitrate  of  silver.  I  have  also 
found  very  great  benefit  from  the  use  of  Wecker's  ointment,  which 
consists  of  equal  parts  of  Oleum  Lini  and  Emplastrum  Plumbi,  with  a 
little  Balsam  of  Peru.  This  is  spread  on  a  pledget  of  lint  and  applied 
to  the  lids  at  bed  time,  being  kept  on  all  night.  On  its  removal  in  the 
morning,  the  eyes  are  to  be  well  sponged  with  warm  water.  Dr.  McCall 
Anderson  strongly  recommends  the  use  of  a  solution  of  potassa  fusa 
(usually  ten  grains  to  an  ounce  of  water),  a  very  little  of  which  is  to 
be  painted  every  day  on  the  edges  of  the  lids  with  a  fine  brush  by  the 
surgeon  himself.  A  large  brush,  soaked  in  cold  water,  should  be  in 
readiness  to  stop  the  action  when  desired.  If  any  conjunctivitis 
co-exists,  a  drop  or  two  of  a  collyrium  of  sulphate  of  zinc,  or  of  alum 
should  be  applied  two  or  three  times  a  day.  The  eyes  should  also  be 
protected  against  bright  light  and  cold  winds  by  a  pair  of  blue  eye- 
protectors.  Together  with  this  local  treatment,  great  attention  must  be 
paid  to  the  patient's  general  health.  If  he  is  of  a  scrofulous  habit,  or 
in  delicate  health,  cod  liver  oil  with  steel  or  quinine  should  be  admiais- 
tered.  His  diet  should  be  nutritious  but  easily  digestible,  and  all  excess, 
more  especially  in  drinking,  should  be  avoided.  Indeed,  even  the 
moderate  use  of  stimulants  cannot  be  borne  by  some  of  these  patients, 
causing  an  aggravation  or  a  relapse  of  the  disease.  In  obstinate  cases, 
I  have  also  derived  much  benefit  from  the  prolonged  use  of  arsenic. 

Acne  ciliaris  is  not  unfrequently  met  with ;  we  then  notice  one  or 
more  small  nodules,  due  to  an  inflammation  of  the  sebaceous  or  hair 
follicles,  and  situated  close  to  the  edge  of  the  Kd,  which  is  more  or  less 
swollen,  red,  and  inflamed ;  indeed,  if  the  attack  is  severe,  the  whole 
lid  may  be  very  cedematous.  These  nodules  are  situated  in  the  subcu- 
taneous cellular  tissue,  and  are  somewhat  moveable,  and  several  cilia  may 
sprout  out  from  the  apex  of  the  little  pustules.  The  latter  gradually 
increase  in  size,  and,  after  having  attained  a  certain  volume,  may 
undergo  resolution;  but  they  generally  suppurate,  the  pus  escaping 
either  through  the  duct  of  the  folKcle,  or  making  its  way  through  the 


678  DISEASES   OF   THE  EYELIDS. 

external  skin.  In  other  cases,  the  nodule  becomes  hardened  and  in- 
dui^ated  (acne  indurata),  and  may  thus  exist  unchanged  for  a  very  long 
time. 

This  disease  is  mostly  met  with  in  youthful  individuals,  who  may  be 
otherwise  in  very  good  health,  excepting  that  they  show  a  disposition  to 
acne  of  the  face.  It  may,  however,  occur  independently  of  this,  if  the 
secretion  of  the  sebaceous  follicles  of  the  eyelids  is  from  any  cause  mor- 
bidly altered ;  so  that,  either  from  its  excess  in  quantity  or  hardness,  it 
becomes  confined  in  the  gland,  and  then  sets  up  inflammation.  On 
account  of  the  larger  size  and  number  of  the  sebaceous  follicles  in  the 
upper  lid,  acne  occurs  more  frequently  in  this  than  in  the  lower.  The 
causes  of  acne  ciliaris  resemble  those  of  acne  in  general,  and,  like  the 
latter,  this  disease  generally  runs  a  protracted  course,  and  is  very  apt 
to  recur.  Amongst  the  principal  causes,  I  may  mention  irregularities  in 
diet,  free  indulgence  in  wine,  spirits,  or  other  excesses  ;  and,  in  females, 
derangement  of  the  uterine  functions.  Exposure  to  dust,  dirt,  cold 
winds,  bright  glare,  etc.,  increases  the  severity  and  obstinacy  of  the 
disease,  and  favours  the  tendency  to  relapses.  If  the  affection  has  lasted 
for  some  time  and  is  accompanied  by  a  good  deal  of  inflarumation,  it 
may  become  complicated  with  blepharitis  marginalis. 

Great  attention  should  be  paid  to  the  cleanliness  of  the  lids,  which 
should  be  frequently  washed,  so  that  any  discharge  which  clogs  the 
lashes,  or  has  become  encrusted  on  the  lids,  may  be  removed.  The 
loose  or  affected  eyelashes  should  be  frequently  plucked  out.  If  the 
nodule  and  the  neighbouring  portion  of  the  lid  are  red,  inflamed,  and 
painful,  cold  compresses  should  be  applied,  but  if  signs  of  suppuration 
appear,  hot  poultices  or  fomentation  should  be  substituted,  and  the 
pustule  be  punctured,  in  order  that  the  discharge  may  find  a  ready  exit. 
In  the  indurated  form,  an  ointment  containing  mercury  or  iodide  of 
potassium  should  be  applied.  The  diet  and  habits  of  the  patient  should 
be  carefully  regulated,  and  if  he  is  feeble  and  delicate  in  health,  tonics 
should  be  adruinistered. 

The  presence  of  lice*  on  the  eyelashes  (phtheiriasis  ciliarum)  might 
be  mistaken  for  tinea,  but  the  crusts  present  a  more  circumscribed  and 
beaded  form.  The  citrine  or  red  precipitate  ointment  should  be  applied 
twice  daily,  which  will  generally  kill  the  pediculi  in  a  few  days.  If 
they  are  numerous,  it  may  be  necessary  to  clip  the  lashes  very  close. 

5.— EPHIDROSIS  AND  CHROMHYDROSIS. 

An  excessive  secretion  of  the  sudoriferous  glands  of  the  Hds,  more 
especially  the  upper,  is  occasionally  met  with.    The  perspiration  exudes 

*  "  R.  L.  O.  H.  Eep.,"  ii,  125. 


HORDEOLUM.  679 

so  freely  tliat  the  surface  of  the  lid  is  covered  by  a  thin  layer  or  film  of 
fluid,  reaching  perhaps  nearly  up  to  the  edge  of  the  orbit.  This  con- 
dition is  termed  Ephidrosis.  On  wiping  the  skin  dry  with  a  fine  dossil 
of  huen,  we  can  easily  notice  (with  the  aid  of  a  magnifying-glass)  that 
the  moisture  exudes  from  inuumerable  little  pores,  flows  together  into 
larger  drops,  and  finally  covers  the  hd  with  a  thin  layer  of  fluid  (Von 
Cxraefe*).  Soon  the  conjunctiva  becomes  somewhat  injected  and 
inflamed,  the  edges  of  the  lids  sore  and  excoriated  (more  especially  at 
the  angles  of  the  eye)  from  the  constant  irritation  of  the  moisture, 
and  an  obstinate  blepharitis  marginalis,  with  a  slight  degree  of  con- 
junctivitis, is  set  up.  The  patient  at  the  same  time  complains  of  a 
peculiar  itching  and  biting  sensation  on  the  outer  surface  of  the  lid. 
The  affection  is  very  obstinate  and  protracted,  for  although  astringent 
lotions  and  collyria  benefit  the  inflammation  of  the  conjunctiva  and  the 
edge  of  the  lid,  they  exert  but  little,  if  any,  influence  upon  the  secretion 
of  fluid.  Wecker  recommends  his  "  Pommade  antiblepharitique " 
(p.  Q>77).  The  general  health,  and  especially  the  action  of  the  skin 
and  kidneys,  should  be  attended  to. 

Cliromliydrosis  (sfcearrhsea  nigricans  of  Erasmus  Wilson).  Under 
this  title  has  been  described  a  very  peculiar  pigmented  condition  of  the 
eyelids,  which  is  characterised  by  the  appearance  of  a  dark  brown  or 
brownish-black  discolouration  of  the  lids,  more  especially  the  lower, 
which  is  chiefly  noticeable  in  the  folds  of  the  skin,  and  does  not  reach 
up  to  the  lashes.  It  can  be  readily  removed  with  oil  or  glycerine,  but, 
apparently,  not  with  water.  It  has  been  chiefly  met  with  in  females, 
more  especially  those  of  a  nervous,  hysterical  temperament,  and  there  can 
be  but  little  doubt  that  it  is  artificial,  being  due  to  some  pigment  painted 
on  by  the  patient  in  order  to  deceive  her  medical  attendant,  and  to 
awaken  interest  or  compassion.  For  a  very  full  account  of  this  con- 
dition, I  would  refer  the  reader  to  The  French  Translation  of  Mackenzie, 
iii,  44,  and  to  a  paper  read  by  Dr.  Warlomont,  before  the  Heidelberg 
Ophthalmological  Congress,  1864,  vide  "  Kl.  Monatsbl.,"  1864,  381. 

6.— HORDEOLUM  (STYE). 

This  disease  is  not,  as  is  sometimes  supposed,  an  inflammatory  affec- 
tion of  the  Meibomian  glands,  but  is  a  furuncular  inflammation  of  the 
connective  tissue  of  the  lids,  having  its  seat  generally  in  the  vicinity 
of  the  hair  follicles,  and  near  the  margin  of  the  lid.  In  most  cases, 
there  is  only  one  boil,  in  others,  there  are  several.  At  the  outset  of 
the  disease,  we  notice  a  small  circumscribed  nodule  or  button  near 
the  edge  of  the  lid,  the  skin  being  freely  moveable  over  it.  If  the 
development  is  very  acute,  the  Hd  is  often  much  inflamed,  very  red,  and 
*  "A.  f.  O.,"  iv,  2,  254. 


680  DISEASES   OF   THE   EYELIDS. 

cedematous ;  and  altliough  these  symptoms  are  generally  confined  to  the 
portion  of  the  lid  in  the  vicinity  of  the  stye,  they  may  extend  to  the 
whole  eyelid.  If  the  upper  lid  is  the  one  affected,  it  may  hang  down 
in  a  massive  fold  and  qnite  close  the  palpebral  aperture,  there  being  at 
the  same  time,  perhaps,  a  good  deal  of  photophobia  and  lachrymation. 
The  patient  generally  complains  of  very  considerable  pain,  and  the 
swelling  in  the  vicinity  of  the  nodule  is  exquisitely  tender  to  the  touch  ; 
sometimes,  there  is  also  a  good  deal  of  feverishness  and  constitutional 
disturbance,  the  sufferings  of  the  patient  being  quite  out  of  proportion 
to  the  extent  of  the  disease.  The  latter  may,  however,  run  a  more 
subacute  or  chronic  course.  The  prominence  produced  by  the  nodule 
is  mostly  at  once  evident  to  the  eye,  assuming  the  appearance  of  a  little 
circumscribed  tumour,  about  the  size  of  a  pea,  the  skin  of  the  lid  in  its 
vicinity  being  of  a  dusky,  angry  red.  Sometimes,  several  lashes  project 
from  its  apex,  if  it  is  situated  at  the  margin  of  the  lid.  If  it  be  not 
visible,  its  presence  may  be  easily  detected  by  lightly  passing  the  tip  of 
the  finger  over  the  surface  of  the  eyelid.  On  eversion  of  the  latter,  the 
conjunctiva  will  generally  appear  smooth  and  unaltered,  but  if  the 
hordeolum  points  inwards,  the  circumscribed  nodule  will  appear  on  the 
inner  surface  of  the  lid,  the  conjunctiva  over  and  around  it  being  red- 
dened and  swollen.  The  apex  of  the  little  button  presents  a  greyish 
yellow  tint,  if  suppuration  has  set  in  and  the  matter  "points."  If  the 
disease  is  allowed  to  run  its  course,  it  may  sometimes  undergo  resolu- 
tion, but,  as  a  rule,  suppuration  sets  in  and  perforation  takes  place,  more 
or  less  thick  purulent  matter  being  discharged,  together  with  which 
there  is  often  mixed  some  greyish-white  gelatinous  substance,  con- 
sisting of  ill-developed  or  broken  down  connective  tissue.  This  is  dis- 
charged in  Httle  lumps.  The  disease  shows  a  very  great  tendency  to 
recur  again  and  again,  so  that  its  existence  may  be  prolonged  for  very 
many  months,  and  this  has  led  some  authorities  to  consider  it  de- 
pendent upon  some  peculiar  diathesis.  It  is  most  frequently  met  with 
in  youthful  individuals,  more  especially  in  those  of  rather  delicate 
health,  who  are  often  subject  to  acne,  or  who  are  addicted  to  free  living 
or  dissipation.  If  the  course  of  the  disease  is  protracted,  and  more 
especially  if  there  are  frequent  relapses,  it  is  not  unfrequently  followed 
by  chalazion,  due  to  inflammatory  changes  in  the  Meibomian  glands, 
and  followed  by  fatty  or  chalky  degeneration  of  their  contents. 

At  the  very  outset  of  the  disease,  more  especially  if  there  are  severe 
inflammatory  symptoms,  cold  compresses  should  be  applied ;  but,  as  a 
rule,  I  prefer  the  use  of  hot  poultices,  which  should  be  changed  very  fre- 
quently ;  for  this  will  greatly  accelerate  the  formation  of  pus,  and 
expedite  the  progress  of  the  case.  "When  suppuration  has  set  in,  and 
the  skin  has  become  thinned  and  yellow  at  one  point,  a  small  incision 
should  be  made  to  permit  of  the  ready  escape  of  the  pus,  with  which 


TUMOURS   OF   THE   EYELIDS.  681 

will  generally  be  mixed  some  of  the  grey  gelatinous  connective  tissue. 
The  pain  is  immediately  and  greatly  relieved  by  the  incision.  When 
cicatrization  has  taken  place,  I  have  found  much  benefit,  in  preventing 
a  recurrence  of  the  disease,  from  the  use  of  a  weak  ointment  of  nitrate 
of  silver  (gr.  ij. — iv.  ad  5J.).  If  the  patient  is  feeble  and  out  of  health, 
tonics  must  be  given,  and  the  digestive  functions  thoroughly  regu- 
lated. 

7.— TUMOURS  OF  THE  EYELIDS. 

Clialazion  (Tarsal  tumour,  Tarsal  cyst)  is  a  tumour  due  to  inflamma- 
tory changes  of  the  Meibomian  glands  or  ducts,  giving  rise  to  an 
alteration  and  retention  of  the  secretions.  If  the  inflammation  has  been 
acute,  or  if  an  acute  inflammatory  exacerbation  has  occurred,  suppu- 
ration may  take  place  and  pus  be  formed.  In  other  cases,  the  contents 
of  the  cyst,  instead  of  bemg  purulent  or  muco- purulent,  are  fluid,  gela- 
tinous, fatty,  or  sebaceous  and  clotted.  The  tumour  is  generally 
about  the  size  of  a  little  pea,  but  may  increase  to  that  of  a  small  bean  ;  it 
is  situated  at  some  distance  from  the  free  margin  of  the  lid,  and  is 
generally  most  manifest  on  its  inner  surfoce,  lying  close  beneath  the 
conjunctiva  (which  is  often  considerably  thimaed),  and  forming  here  a 
small,  circumscribed,  bluish  or  yellowish- white  tumour,  which  springs 
prominently  into  view  when  the  lid  is  well  everted  and  the  conjunctiva 
put  upon  the  stretch.  In  other  and  rarer  cases,  the  tumour  points  out- 
wards and  lies  close  beneath  the  skin,  which  is  frequently  somewhat 
reddened  and  thinned  over  and  around  it.  It  occui's  far  moj^e  frequently 
in  the  upper  than  in  the  lower  Ud.  Sometimes,  it  may  exist  in  both  eye- 
lids, or  in  both  eyes. 

If  the  tumour  is  small  and  hard,  and  its  formation  has  been 
extremely  slow,  we  may  endeavour  to  favour  its  absorption  by  the  use  of 
red  precipitate  or  iodide  of  potassium  ointment,  but  as  a  rule  this 
proves  quite  inefiectual,  and  we  must  generally  have  recourse  to  opera- 
tive interference.  If  the  tumour  presents  upon  the  conjunctival 
surface,  the  lid  should  be  thoroughly  everted,  and  the  conjunctiva  put 
upon  the  stretch,  so  as  to  render  the  little  nodule  prominent  and  tense. 
A  free  crucial  incision  should  then  be  made  into  it  with  a  cataract 
knife  or  small  scalpel,  so  that  it  may  be  laid  well  open.  If  the  contents 
are  fluid  or  muco-purulent,  they  will  at  once  escape  ;  if  this  is,  however 
not  the  case,  and  they  are  somewhat  coherently  gelatinous,  a  small 
curette  should  be  introduced,  and  gently  turned  round,  so  as  to  break 
down  and  scoop  out  the  contents.  Should  small  portions  of  the  latter 
adhere  to  the  wall  of  the  cyst,  they  should  be  snipped  ofi"  with  a  pair 
of  scissors  curved  on  the  flat.  If  the  tumour  is  deeply  seated  and 
near  the  outer  surface,  the  incisions  must  be  proportionately  deep,  and 


682  DISEASES   OP   THE   EYELIDS. 

extend  througli  the  tarsus,  as  it  is  generally  better  to  open  the  tumour, 
if  possible,  from  within,  for  we  thus  avoid  the  formation  of  a  cicatrix 
in  the  skin.  Special  attention  must  be  paid  to  this  if  the  chalazion  is 
situated  near  the  margin  of  the  lid,  and  particularly  near  the  punctum, 
for  then  the  cicatrix  would  be  very  prone  to  produce  a  certain  degree 
of  eversion  of  the  edge  of  the  lid,  and  displacement  of  the  punctum. 
But  if  the  tumour  is  situated  at  some  distance  from  the  edge  of  the 
lid  and  in  its  central  or  outer  portion,  lying  close  beneath  the  skin,  and 
if  the  latter  is  lax,  the  incision  may  be  made  from  the  outside ;  for  the 
wrinkles  of  the  loose  skin  will  hide  the  cicatrix  and  prevent  the  danger 
of  eversion.  The  removal  of  the  contents  is  generally  accompanied  by 
considerable  bleeding,  and  the  tumour  may,  hence,  appear  to  be  hardly 
reduced  in  size.  But  in  the  course  of  a  few  days,  the  adhesive  inflam- 
mation supervening  on  the  operation  will  cause  a  contraction  of  the 
cyst,  and  it,  and  the  thickening  of  the  structures  in  its  vicinity,  will 
rapidly  disappear.  This  adhesive  inflammation  may  be  augmented  by 
lightly  touching  the  interior  of  the  cyst  with  a  finely  pointed  crayon  of 
nitrate  of  silver. 

If  the  tumour  is  hard  and  firm,  I  generally  direct  the  patient  to 
apply  hot  poultices  for  a  day  or  two  before  the  incision,  as  this  acce- 
lerates any  tendency  to  suppuration,  and  softens  the  contents  so  that 
they  are  less  tenacious  and  more  easily  removed.  As  patients  afiected 
with  chalazion  often  sufier  from  irregularities  of  the  digestive  functions, 
these  should  be  carefully  attended  to. 

The  Meibomian  follicles  sometimes  become  obstructed,  A\ithout 
there  being  any  swelling  or  dilatation  of  the  glands.  These  obstruc- 
tions are  due  to  an  accumulation  of  the  secretion  in  the  ducts,  giving 
rise  to  small  yellowish-white  concretions,  either  studded  irregularly 
about  the  smooth  conjunctival  surface,  or  arranged,  perhaps,  in  single 
file,  like  little  pin's  heads,  along  the  coiu'se  of  the  duct.  If  these  are 
very  small,  few  in  number,  and  unattended  with  any  inconvenience  or 
irritation,  we  need  not  interfere  ;  but  if  they  are  numerous,  large  in 
size,  and  productive  of  irritation,  they  should  be  pricked  with  the  point 
of  a  knife,  and  the  hardened  contents  squeezed  out,  or  their  removal 
may  be  facilitated  by  using  a  grooved  spud. 

Milmm  is  a  minute  white  tumour,  about  the  size  of  a  millet  seed, 
l^R!ife'"tfcs  -name,  which  is  mostly  situated  at  or  near  the  free  edge  of 
the  lid.  It  generally  occurs  isolated,  although  perhaps  in  considerable 
numbers,  or  the  tumours  may  be  arranged  in  clusters.  The  cilia  sprout 
forth  from  the  centre  of,  and  between,  these  little  nodules.  The  latter 
should  be  pricked,  and  their  soft,  suet-like  contents  squeezed  out. 

Mollusoiim,  or  albtiminoid  tumour  is  of  the  same  nature  as  milium, 

but^ttStef^  much  more  considerable  size,  and  is  generally  situated  at 
some  little  distance  from  the  edge  of  the  lid,  and  is  quite  painless. 


TUMOURS   OP   THE   EYELIDS.  683 

The  skin  over  it  is,  as  a  rule,  somewliat  thinned,  so  that  its  yel- 
lowish-white colour  and  nodulated  sui'face  are  very  evident.  In  its 
centre  is  sometimes  noticed  a  minute  opening,  through  which  a  little 
white  fluid  exudes,  and  drying,  forms  a  little  brittle  crust  upon  it.  In 
recent  cases,  this  matter  is  contagious.  If  the  tumour  exists  for  a  very 
long  time,  its  attachment  to  the  skin  may  be  stretched  and  elongated, 
so  that  it  has  a  more  or  less  distinct  neck  or  pedicle,  which  renders  it 
pendulous.  Molluscum  is  generally  not  confined  to  the  lids,  but  occurs 
at  the  same  time  upon  the  face  and  other  parts  of  the  body.  The  crust 
upon  its  apex  should  be  detached  with  a  pair  of  forceps,  the  nodule 
pricked  or  slightly  incised,  and  the  contents  squeezed  out  between  the 
thumb  nails.  If  it  is  not  emptied  at  once,  the  pressure  should  be 
repeated.  When  several  mollusca  exist  on  the  eyelids  and  face,  it  is 
better  to  operate  upon  them  all  at  one  sitting. 

Sebaceous  tumours  occur  most  frequently  in  children,  and  resemble 
molluscum  in  their  nature,  but  attain  a  still  more  considerable  size, 
reaching  perhaps  that  of  a  large  filbert  or  even  a  small  walnut.  They 
occur  most  frequently  at  the  outer  and  upper  margin  of  the  orbit,  close 
to  the  eyebrow.  The  skin  over  the  tumour  generally  retains  its  normal 
appearance,  or  may  become  somewhat  reddened.  The  contents  are 
enclosed  in  a  cyst  wall,  the  posterior  portion  of  which  is  somewhat 
thickened  and  hypertrophied,  and  are  suet- like  and  sebaceous,  consisting 
of  broken  down  epithelial  cells,  fat  molecules  and  hairs.  In  other  cases, 
the  tumour  is  softer,  and  its  contents  more  oily.  If  it  is  very  small  and 
its  appearance  does  not  annoy  the  patient,  it  may  be  left  untouched,  but, 
otherwise,  it  should  be  removed  at  an  early  stage.  As  in  order  to 
prevent  its  return,  it  is  necessary  to  remove  it  whole,  it  is  better  not  to 
puncture  it  and  squeeze  out  its  contents,  but  to  dissect  it  out,  if  possible 
without  tearing  or  pricking  the  cyst  wall.  Hence,  a  free  incision  should 
be  made  through  the  skin,  with  a  cataract  knife  or  small  scalpel,  and 
parallel  to  the  edge  of  the  orbit.  When  the  tumoiir  is  of  considerable 
size,  a  crucial  incision  may  be  made  so  as  to  facilitate  the  dissection,  but 
generally  one  long  incision  will  suffice.  The  tumoiu'  should  then  be 
slowly  and  carefully  dissected  away,  the  adhesions  between  the  cyst- 
wall  and  the  surrounding  cellular  tissue  being  delicately  severed  with 
the  point  of  the  knife,  or  detached  by  gentle  traction,  assisted  perhaps 
with  the  end  of  the  handle  of  the  knife.  An  assistant  should  be  ready 
with  a  sponge,  to  wipe  away  the  blood,  so  that  the  operator  may  con- 
stantly have  a  good  view  of  the  outline  of  the  tumour  and  its  adhesions, 
otherwise,  the  cyst- wall  may  easily  be  pricked,  and  its  white  pultaceous 
contents  begin  to  escape,  which  greatly  increases  the  difficulty  of  com- 
pletely removing  the  tumour.  If  the  cyst-wall  has  not  been  removed 
entire,  the  remaining  portions  may  be  lightly  touched  with  nitrate  of 
silver.     In  order  to  accelerate  the  union,  the  edges  of  the  wound  should 


684  DISEASES  OF   THE   EYELIDS. 

be   brought  together  with    fine   sutures,  and   cold  water  dressing  be 
applied. 

Flhrom.a  is  met  with  in  the  eyelids  in  the  form  of  a  small,  hard, 
circumscribed  tumour,  being  sometimes  congenital,  and  occasionally 
exquisitely  painful  to  the  touch.  These  tumours  occasionally  assume  a 
cartilagineous  character,  and  spring  prominently  into  view  when  the 
eyelid  is  everted,  looking  like  a  second  tarsal  cartilage  (Wecker). 
Von  Graefe*  reports  a  tumour  of  this  kind,  occurring  at  the  outer 
angle  of  the  eye,  and  which  had  attained  the  size  of  half  a  hazel  nut.  It 
was  situated  in  the  submucous  connective  tissue,  and,  on  removal,  was 
found  to  consist  of  true  bone  tissue. 

Fibromas  increase  but  very  slowly  in  size,  and  this  forms  the 
chief  distinguishing  feature  between  them  and  sarcomatous  tumours, 
for  they  cannot  be  distinguished  with  certainty  from  the  latter  except 
with  the  microscope. 

Under  the  term  cylindroma  Von  Graefe  describes  a  pecuUar  tumourf 
which  is  sarcomatous  in  its  nature,  and  is  met  with  in  close  vicinity  to 
the  eye,  e.g.,  the  eyelids,  orbit,  etc.,  or  the  head.  It  is  particularly 
distinguished  by  the  fact  that,  together  with  its  sarcomatous  structure, 
it  shows  peculiar  club-shaped  outgrowths  from  the  capillaries  and  veins 
(Recklinghausen]:).  The  tumour  is  very  painful  if  firmly  pressed,  but 
spontaneous  pain  only  occurs  periodically.  It  shows  a  tendency  to 
recur  after  removal,  as  it  is  very  difficult  to  extirpate  it  completely. 

Wads  occasionally  form  on  or  near  the  edges  of  the  eyehds,  and 
should  be  snipped  ofi"  with  a  pair  of  scissors,  or  touched  with  caustic 
or  acetic  acid.  If  their  base  is  narrow,  a  silk  or  fine  horse-hair  ligature 
should  be  applied,  so  as  to  strangulate  it,  which  will  cause  the  wart  to 
drop  ofi"  in  the  course  of  a  few  days. 

Fatty  tumours  are  not  of  frequent  occurrence  in  the  eyelids,  they 
may  generally  be  readily  recognised  by  their  smooth,  circumscribed, 
somewhat  lobulated  form,  and  are  firm  and  elastic  to  the  touch.  Their 
progress  is,  as  a  rule,  extremely  slow,  and  they  can  be  readily  re- 
moved. 

EpitJielial  cancer  is  almost  the  only  malignant  tumour  which  occurs 
primarily  in  the  eyelids,  for  the  other  forms,  such  as  scirrhus,  medullary 
cancer,  etc.,  are  generally  only  secondarily  met  with  in  this  situation. 

Epithelial  cancer  shows  itself  most  frequently  in  the  lower  eyelid, 
and  near  the  outer  canthus.  It  occurs  generally  in  persons  above 
the  age  of  forty,  or  even  in  those  much  more  aged,  being  rarely  met 
with  in  youthful  individuals.  At  the  outset,  the  disease  assumes  the 
appearance  of  a  small,    circumscribed,    slightly  elevated  induration, 

*  "  Kl.  Moiiatsbl.,"  1863,  p.  23. 
t  "  A.  f.  O.,"  X,  1,  184.  X  Ibid.,  190. 


TUMOURS   OF   THE   EYELIDS.  685 

situated  at,  or  close  to,  the  edge  of  the  lid,  and  looking  like  a  wart  or  a 
small  thickened  crust.  It  is  covered  by  healthy-looking,  iininflamed 
skin,  and  a  few  varicose  vessels  are  perhaps  seen  to  pass  over  or  near  it. 
The  surface  of  the  little  nodule  often  looks  rough  and  scaly,  as  if  the 
cuticle  were  thickened.  It  may  remain  in  this  condition  for  a  very 
long  period,  and  years  may  elapse  before  it  increases  materially  in  size, 
or  becomes  ulcerated.  On  this  account,  and  from  its  being  quite  pain- 
less, it  is  often  entirely  disregarded  by  the  patient,  who  supposes  it  to 
be  simply  a  wart.  When  the  disease  occurs  in  the  skin  over  the 
lachrj^mal  sac,  it  has  been  mistaken  for  dacryocystitis.  Thus  Mackenzie 
mentions  one  instance,  in  which  the  patient  called  to  have  a  style  intro- 
duced, and  another,  in  which  one  had.  actually  been  worn.  But  sooner 
or  later  it  gradually  and  almost  imperceptibly  increases  somewhat  in 
size,  creeping  along  the  edge  of  the  lid  and  assuming  a  lengthened, 
ovoid  shape.  Its  surface  becomes  broken  and  excoriated,  and  a  thin, 
greyish-yellow  discharge  exudes  from  it,  which  hardens  upon  it  in  the 
form  of  dark,  rough  crusts.  Then  ulceration  sets  in,  and  the  tumour 
slowly  spreads  in  circumference  and  depth,  the  edges  of  the  ulcer  being 
somewhat  elevated,  and  studded,  perhaps,  with  a  fewpalish-red  tubercles, 
which  rapidly  form  again  if  abscised.  The  skin  around  the  tumour  is 
but  little  tliickened,  swollen,  or  discoloured,  and  this  distinguishes  the 
disease  from  lupus,  and  also  from  syphilitic  ulcer.  Moreover,  the 
slowness  of  its  growth  and  the  history  of  the  case,  would  prevent  its 
being  mistaken  for  the  latter.  When  the  ulceration  sets  in,  the  pain 
increases,  but  seldom  to  any  considerable  degree,  nor  is  it  of  a  very 
acute,  lancinating  character,  but  if  any  nerves  are  exposed  by  the  ulcera- 
tion, the  patient's  sufferings  will  of  course  be  much  augmented.  The 
discharge  is  of  a  yellowish  colour,  healthy  in  nature,  and  free  from 
fetor.*  Sometimes,  the  ulcer  may  become  temporarily  cicatrised, 
either  completely  or  in  part,  and  then  remain  apparently  healed  for  a 
certain  time ;  but  soon  a  breach  of  surface  again  occurs,  and  fresh 
ulceration  sets  in.  In  time,  the  ulcer  invades  the  lid  more  and  more, 
spreading  along  its  surface  and  extending  deeply  into  its  structure, 
until  it  may  eat  its  way  completely  through  its  whole  thickness,  and 
appear  on  the  conjunctival  siirface  ;  thence,  perhaps,  extending  to  the 
orbit.  If  the  lids  are  destroyed,  the  eyeball  will  be  exposed,  and  sup- 
puration of  the  cornea  may  ensue,  accompanied  perhaps  by  loss  of  the 
lens  and  a  considerable  portion  of  the  vitreous  humour,  and  followed 
by  atrophy  of  the  globe.  Mackenzief  has  witnessed  the  most  excru- 
ciating pain  ensuing  upon  implication  of  the  eyeball,  or  when  the 
ulceration  affected  the  infra-oi'bitary  and  supra-orbitary  nerves.  The 
disease  may  also  extend  to  the  face,   finally  opening  into  the  mouth. 

*  Vide  Dr.  Jacob's  able  paper  ou   this   disease,  "Dublin  Hospital  Ecports," 
vol.  iv,  1827.  t  "  Diseases  of  the  Eye,"  4th  ed.,  137. 


686  DISEASES  OF   THE  EYELIDS. 

The  veins  whicli  pass  over  the  ulcer  often  give  way  and  cause  very 
considerable  haemorrhage. 

The  cause  of  the  disease  is  frequently  dubious,  but  sometimes  we 
are  able  distinctly  to  trace  its  origin  to  some  injury  or  blow,  or  the 
existence  of  some  prolonged  source  of  irritation. 

If  the  disease  is  moderate  in  extent  and  circumscribed,  so  that  there 
is  hope  of  entirely  removing  it,  the  treatment  by  extirpation  is,  I  think, 
as  a  rule,  the  best ;  care  being  taken  to  carry  the  incisions  through  the 
healthy  integuments,  for  fear  of  leaving  any  of  the  morbid  tissue  be- 
hind. The  incision  is  generally  made  of  a  V  shape,  and  sufficiently 
large  to  include  all  the  diseased  portion  within  it.  The  edges  of  the 
wound  should  be  brought  together  with  fine  sutures  ;  or  if  the  loss  of 
substance  is  considerable,  a  plastic  operation  should  be  performed,  and 
the  skin  brought  from  the  temple  or  cheek.  Mackenzie,  however, 
prefers  to  make  a  semilunar  incision,  and  to  allow  the  wound  to  heal 
by  granulation.  It  must  be  admitted,  however,  that  even  when  the 
operation  has  been  followed  by  a  firm  cicatrix,  and  the  disease  has 
appeared  to  have  been  cured,  that  after  a  time  a  relapse  has  taken 
place ;  and  hence  the  treatment  by  escharotics  and  other  agents  has 
been  strongly  recommended.  Potassa  fusa  and  the  chloride  of  zinc 
paste  have  been  especially  used  as  caustics.  Mackenzie*  strongly 
recommends  the  sulphate  of  zinc  for  this  purpose.  The  water  of 
crystallisation  of  the  sulphate  of  zinc  having  been  driven  ofi"  by  heat, 
and  the  residuum  reduced  to  a  fine  powder,  he  mixed  it  with  a  little 
glycerine,  so  as  to  form  a  thick  tenacious  paste,  and  on  the  point  of  a  bit 
of  stick,  applied  it  over  the  scab  and  the  hard  edges  of  the  ulcer ;  the 
part  being  then  covered  with  a  bit  of  dry  lint.  This  treatment  was 
repeated  two  or  three  times,  and  produced  a  firm,  healthy  cicatrix,  and 
apparently  an  excellent  cure. 

Dr.  Broadbent's  treatment  by  injection  of  acetic  acid  (one  part  of 
strong  acid  to  about  four  of  water)  may  also  be  tried,  and  has  proved 
very  successful  in  the  hands  of  several  distinguished  surgeons,  amongst 
others,  Mr.  Power, f  M.  Wecker,|  etc.  Dr.  Althaus's  treatment  by 
electrolysis  may  also  be  tried,  being  quite  free  from  any  pain  or  discom- 
fort. M.  Bergeron§  recommends  the  internal  and  local  use  of  chlorate 
of  potash. 

8.— N^VUS  MATERNUS  (TELANGIECTASIS). 

This  disease  is  occasionally  met  with  on  the  eyelids,  and  may 
vary  considerably  in  size  and  appearance.     Its  surface  may  be  smooth 

*  "  E.  L.  O.  H.  Rep.,"  ii,  5. 

t  Mr.  Power  on  Diseases  of  the  Eye,  p.  103. 

:J:  Wecker,  "  Maladies  cles  Yeux,"  2nd  edition,  i,  659. 

§  lb.,  p.  659. 


PTOSIS.  687 

and  even,  or  granulated,  and  perhaps  divisible  into  two  or  three  distinct 
portions.  The  colour  also  varies  from  a  light  scarlet  to  a  dark  bluish- 
red  or  purple.  Ntevi  may  be  quite  superficial  and  confined  to  the  skin, 
or  extend  deeper  and  implicate  the  subcutaneous  tissue,  perhaps  to  a 
considerable  extent.  They  have  also  been  divided  into  an  arterial  or 
active,  and  a  venous  or  passive  form.  The  former  are  firm  and  dis- 
tinctly pulsatile  to  the  touch,  and  cannot  be  emptied,  except  the  vessels 
which  supply  them  are  compi'essed  (Mackenzie).  The  venous  arc 
softer  and  more  elastic,  and  can  be  easily  emptied  by  pressure.  On 
the  patient's  stooping  down,  the  ngevus  rapidly  sweDs  up,  and  becomes 
dark  and  very  tense. 

The  disease  is  often  congenital,  and  may  increase  gradually  up  to  a 
certain  point,  and  then  remain  almost  stationary,  or  else  it  may  spon- 
taneously diminish  in  size,  and  slowly  disappear  without  leaving  a 
trace  behind. 

Various  modes  of  treatment  have  been  recommended  for  this 
disease.  Of  these  the  best  are,  I  think,  the  application  of  threads 
soaked  in  perchloride  of  iron,  the  various  forms  of  ligature,  and  elec- 
trolysis. Injection  of  the  perchloride  of  iron  is  excessively  dangerous, 
and  several  cases  of  instantaneous  death  have  been  recorded.  Hence  it 
is  far  wiser  to  traverse  the  tumour  in  difierent  directions  with  threads 
dipped  in  perchloride  of  iron,  and  to  allow  them  to  remain  in  for  a 
few  days.  The  subcutaneous  ligature,  either  a  figure  of  8,  or  circular, 
also  proves  very  successful.  If  the  tumour  is  considerable  in  size,  and 
divisible  into  several  portions,  one  of  these  may  be  taken  at  a  time, 
and  the  operation  repeated  several  times.  Wecker*  transfixes  the  base 
of  the  little  tumoiu*  by  two  needles  crossed  at  right  angles  (  +  ),  and 
then  firmly  strangulates  the  base  with  a  tlu'ead  passed  beneath  the 
needles. 

The  appHcation  of  electrolysis  to  these  neevi,  appears  to  me  to  be 
veiy  serviceable.  Dr.  Althaus,t  to  whom  we  are  indebted  for  the 
introduction  of  this .  mode  of  ti^eatment,  has  found  it  very  successful, 
and  narrates  a  case  in  which  a  nsevus  of  the  eyelid  (in  a  patient  of 
Mr.  Wliite  Cooper)  was  rapidly  cured  without  leaving  any  trace  be- 
hind. The  great  advantages  of  electrolysis  are,  that  it  is  free  from 
all  pain  and  danger,  and  that  it  does  not  leave  any  scar  or  disfigure- 
ment. 

Galvano-puncture  has  also  been  recommended. 

9.— PTOSIS. 

In  this  afiection  the  upper  eyelid  droops  down,  so  that  the  palpe- 
bral aperture  is  greatly  narroAved,  and  the  cornea  more  or  less  covered, 
*  L.  c,  653. 
t  Vide  Dr.  Althaus's  interesting  work  on  Electrolysis. 


688  DISEASES   OF  THE  EYELIDS. 

the  patient  being  unable  by  a  voluntary  effort  to  raise  the  lid.  In  the 
chapter  upon  the  paralytic  affections  of  the  muscles  of  the  eye,  it  was 
mentioned  that  ptosis  is  a  frequent  symptom  in  paralysis  of  the  third 
nerve,  on  account  of  the  levator  pcdpehrce  superioris  being  supplied  by 
this  nerve.  In  a  complete  paralysis  of  the  third  nerve,  -we  should 
find,  besides  the  ptosis,  that  on  our  lifting  the  patient's  eyelid,  the  eye 
would  be  immoveable  in  all  directions  except  outwards,  that  the  pupil 
would  be  dilated  and  the  power  of  accommodation  paralysed.  The 
ptosis  may  be  either  partial  or  complete ;  in  the  former  case,  the  upper 
lid  can  still  be  somewhat  lifted,  and  does  not  droop  to  the  full  extent, 
in  the  latter,  it  hangs  down  quite  immoveable,  and  has  to  be  lifted  up 
by  the  assistance  of  the  finger.  The  palpebral  aperture  may,  however, 
be  somewhat  widened,  and  the  upper  lid  slightly  elevated  by  the 
relaxation  of  the  orbicularis  and  the  contraction  of  the  frontalis  muscle. 
The  causes  of  the  paralysis  of  the  third  nerve  have  already  been  men- 
tioned at  p.  565,  and  I  need  not  here  recur  to  them.  It  must  be 
stated,  however,  that  in  some  rare  instances,  the  branch  to  the  levator 
palpebrae  may  be  alone  implicated,  owing  to  its  direct  compression  by 
an  exostosis,  tumour,  etc.,  the  other  branches  of  the  third  nerve  being 
unaffected.  Or  again,  sorae  tx^aumatic  lesion,  implicating  the  nerve  or 
the  muscle  itself,  may  be  the  cause.  Ptosis  may  also  occur  independ- 
ently of  any  paralytic  affection,  being  due  to  some  want  of  development 
or  congenital  insuflB.ciency  of  the  levator  palpebree,  which  co-exists 
sometimes  with  epicanthus.  Or  it  may  remain  after  the  great  swelling 
of  the  lid  and  hypertrophy  of  the  conjunctiva  accompanying  purulent 
or  granular  ophthalmia,  the  levator  not  being  sufficiently  strong  to 
overcome  the  weight.  A  certain  degree  of  ptosis  is  also  sometimes 
observed  in  aged  people,  if  there  is  a  great  superabundance  of 
flaccid  skin,  and  the  levator  palpebrjB  is  at  the  same  time  somewhat 
weak. 

The  treatment  must  be  varied  according  to  the  cause  of  the  affec- 
tion. If  it  be  due  to  paralysis,  the  general  line  of  treatment  laid  down 
in  the  chapter  upon  the  Paralytic  Affections  of  the  Eye  (p.  567)  must 
be  followed.  Electricity  often  proves  of  considerable  benefit.  But  if 
the  disease  resists  all  these  remedies,  recourse  must  be  had  to  opera- 
tive interference.  In  those  cases,  in  which  the  ptosis  is  simply  due  to 
an  over-abundance  or  hyjjertrophy  of  the  skin,  a  horizontal  fold  of  the 
latter,  parallel  to  the  edge  of  the  lid,  should  be  pinched  up  with  a  pair 
of  forceps  and  excised,  the  edges  of  the  wound  being  united  by  fine 
sutures. 

The  attempt  has,  moreover,  been  made  by  Bowman  and  Von  Graefe 
to  bring  forward  the  insertion  of  the  levator  palpebrge,  and  thus  aug- 
ment it;'  power,  on  the  same  principle  upon  which  the  insertion  of 
some  of  the  ocular  muscles  is  sometimes  brought  forward.     But  the 


PARALYSIS   OF   THE   ORBICULARIS  PALPEBRARUM.  G89 

results  were  not  favourable.  Von  Graefe*  Las  more  lately  devised  the 
following  operation  : — A  transverse  incision  is  made  through  the  skin 
of  the  upper  lid  about  2^^  lines  from  its  free  margin,  and  extending  the 
whole  length  of  the  lid,  the  incision  being  made  to  gape  by  a  vertical 
traction  upon  its  edges,  and  by  somewhat  separating  the  subcutaneous 
cellular  tissue  with  the  knife.  When  a  sufficient  breadth  of  the  orbi- 
cularis has  been  thus  exposed,  it  is  to  be  seized  with  the  forceps,  and 
a  portion  of  about  four  or  five  lines  in  width  is  to  be  excised,  care 
being  taken  not  to  injure  the  subjacent  fascia.  The  incision  is  then  to 
be  united  by  sutures,  wliich  are  to  be  carried  through  the  skin  and  the 
cut  edges  of  the  orbicularis.  The  effect  of  this  operation  is  to  cause  a 
subcutaneous  shortening  of  the  upper  lid,  to  weaken  the  action  of  the 
orbicularis,  and  thus  to  assist  that  of  the  levator.  If  the  length  of  the 
lid  is  increased.  Von  Graefe,  after  having  finished  the  transverse  in- 
cision, makes  a  second,  having  its  convexity  upwards,  so  that  a 
shortening  of  the  skin  may  be  combined  with  the  subcutaneous  short- 
ening of  the  lid. 


10.— PARALYSIS  OF  THE  ORBICULARIS  PALPEBRARUM. 

In  this  affijction  we  find  that  the  eyelids  cannot  be  completely 
closed,  on  account  of  the  inefficient  elevation  of  the  lower  lid,  so  that 
a  chink  of  varying  size  exists  between  the  two  lids.  By  a  strong 
effort  of  the  will,  the  patient  may  succeed  (more  easily  if  the  other  eye 
is  closed),  in  almost  shutting  the  lids  by  the  relaxation  of  the  levator 
palpebrfe.  The  wide  gaping  of  the  eyelids  gives  a  pecuharly  staring 
appearance  to  the  patient,  and  is  termed  lagophthahnos.  The  paralytic 
lagophthalmos  is  present  even  during  sleep,  and  resists  the  action  of 
reflex  ii'ritants  applied  to  the  conjunctiva.  Paralysis  of  the  orbicularis 
is  soon  followed  by  other  symptoms.  There  is  marked  epiphora,  and 
the  constant  flowing  of  the  tears  over  the  cheek  soon  causes  irritation 
and  excoriation  of  the  edges  of  the  lids,  upon  which  thickening  and 
eversion  supervene.  The  exposure  of  the  eye  to  external  irritants 
(such  as  particles  of  dust,  etc.)  soon  produces  conjunctivitis  and 
supei'ficial  corneitis,  ending,  perhaps,  in  pannus  and  xerophthalmia. 

The  affection  of  the  orbiculaiis  is  due  to  paralysis  of  the  portio 
dura.  The  orbicularis  may  be  alone  affected,  or  the  paralysis  may 
extend  to  several,  or  all  the  branches  of  the  portio  dura.  It  is  only 
very  rarely  met  together  with  hemiplegia.  The  causes  of  the  disease 
may  be  peripheral  or  central.  Amongst  the  former,  exposure  to  cold 
air,  damp,  etc.,  is  the  most  frequent.  It  may  also  be  caused  by  direct 
pressure  (as  from  a  tumour)  upon  any  part  of  the  nerve,  or  by  in- 

*  "A.  f.  O.,"  ix,  2,  57. 

2  y 


690  DISEASES  OF  THE   EYELIDS. 

juries  which  implicate  the  latter.  Amongst  the  cerebral  causes,  need 
only  be  mentioned  the  presence  of  tumours,  syphilitic  exudations, 
hemorrhagic  or  purulent  effusions,  etc.,  and  different  lesions  situated 
at  the  base  of  the  brain.  If  the  disease  is  due  to  paralysis,  the  treat- 
ment laid  down  in  the  article  upon  paralytic  affections  of  the  muscles 
of  the  eye  should  be  pursued. 


11.— BLEPHAROSPASM. 

This  affection  varies  much  in  intensity.  In  slight  degrees,  there 
may  only  exist  a  moderate  degree  of  temporary  twitching  and  con- 
traction of  the  lids,  which  soon  passes  off  again.  In  very  severe  forms, 
the  spasm  of  the  orbicularis  may  be  so  great,  that  the  eyehds  are  firmly 
pressed  together,  and  that  it  is  quite  impossible  for  the  patient  or  the 
surgeon  to  open  them  even  to  a  slight  degree.  The  endeavour  forcibly 
to  open  the  eye  is  intensely  painful,  and  may  even  almost  throw  the 
patient  into  epileptiform  convulsions.  At  the  outset,  the  disease  is 
generally  but  moderate,  but  if  the  cause  persists,  or  efficient  treatment 
is  not  adopted,  it  gradually  increases  in  severity,  and  the  spasm,  which 
was  before  perhaps  only  periodical,  becomes  permanent,  so  that  the 
patient  cannot  open  his  eye  at  all.  Then  the  other  eye  may  become 
affected  in  a  similar  manner,  and  the  muscles  of  the  face,  neck,  and 
even  of  the  extremities,  may  undergo  spasmodic  contractions.* 

Blepharospasm  is  often  met  with  in  the  course  of  inflammatory 
affections  of  the  cornea  and  conjunctiva,  or  if  a  foreign  body  has  become 
lodged  within  the  folds  of  the  latter.  In  such  cases,  it  is  evidently 
due  to  a  reflex  neurosis  dependent  upon  irritation  of  some  of  the 
branches  of  the  fifth  nerve.  This  disease  likewise  occurs  in  severe 
cases  of  hypersesthesia  of  the  retina.  It  is  also  observed  in  connection 
with  neuralgia  of  the  supra-orbital  nerve,  or  of  other  branches  of  the 
fifth ;  the  exact  seat  of  these  affections  being  perhaps  unsuspected  until  a 
certain  spot  is  found,  where  firm  pressure  will  at  once  arrest  the  spasm. 
It  must  be  mentioned,  however,  that  in  some  instances  even  direct 
pressure  upon  the  facial  nerve  at  its  exit  through  the  stylo-mastoid 
foramen,  will  stop  the  blepharospasm  (Romberg). 

The  treatment  of  the  disease  must  vary  with  the  cause  and  dura- 
tion. Thus  the  severe  blepharospasm  often  noticed  in  the  course  of 
corneal  affections  disappears  with  them  ;  or  if  it  persists,  it  often  yields 
to  tonics,  immersion  of  the  head  in  cold  water,  sea  bathing,  and  the 
subcutaneous  injection  of  morphia.  Indeed,  the  latter  remedy  is  often 
found  of  great  benefit  in  the  treatment  of  these  spasmodic  affections. 
From  one-sixth  to  one-third  of  a  gi-ain  of  morpliia  should  be  injected 

*  "A.  f.  0.,"i,  1,440. 


BLEPHAROSPASM.  691 

at  the  point  where  pressure  will  stop  the  spasm,  and  be  occasionally 
repeated.  If,  however,  these  remedies  fail  to  cure  the  blepharospasm, 
and  if  pressure  upon  the  supra-orbital  nerve  stops  it,  and  enables  the 
patient  momentarily  to  open  his  eye,  this  nerve  must  be  divided.  This 
operation  was  first  performed  by  Von  Graefe,  at  Romberg's  suggestion, 
in  a  case  of  intense  blepharospasm  which  had  supervened  upon  the 
lodgement  of  a  foreign  body  in  the  folds  of  the  conjunctiva.  It  was 
evidently  a  case  of  hy|Der£esthesia  of  the  orbicularis  from  contusion,  and 
was  considered  by  Romberg  to  be  a  reflex  spasm  due  to  a  pathological 
irritation  of  the  sensory  nerves.  He,  therefore,  advised  the  division  of 
the  supra-orbital  nerve,  from  which  recurrent  (sensory)  branches  are 
probably  distril^uted  to  the  orbicularis.  The  operation  proved  per- 
fectly successful,  and  has  since  then  been  often  repeated  by  Graefe 
and  other  surgeons  with  much  benefit.  The  supra-orbital  nerve  should 
be  divided  close  to  its  exit  from  the  supra-orbital  foramen,  and  in 
order  to  facilitate  this,  the  eyebrow  should  be  drawn  well  upwards,  so 
as  to  make  the  skin  tense.  If  the  nerve  is  not  completely  divided, 
the  efiect  will  only  be  slight  or  temporary,  and  the  operation  should  be 
repeated.  As  this  non-success  may  sometimes  be  due  to  a  reunion  of 
the  divided  ends  of  the  nerve,  some  surgeons  have  cut  out  a  piece  of 
the  latter.  After  the  operation,  there  should  be  a  certain  degree  of 
ansesthesia  just  above  the  divided  portion  of  the  nerve,  and  in  the 
upper  lid.  The  operation  should  be  performed  under  chloroform,  more 
especially  in  children.  Prior  to  its  performance,  the  surgeon  should, 
of  course,  try  whether  the  firm  compression  of  the  supra-orbital  nerve 
alleviates  the  blepharospasm,  for  only  in  such  cases  can  we  expect  a 
favourable  result. 

Nictitation,  or  involuntary  convulsive  twitching  of  the  eyelids,  is 
occasionally  met  with  in  a  varying  degree,  and  is  generally  owing  to  a 
reflex  neurosis  producing  a  spasmodic  contraction  of  the  orbicularis ; 
these  tviritchings  following  each  other  in  rapid  succession.  The  afiec- 
tion  may  be  limited  to  one  eye,  or  involve  both,  the  upper  lid  being 
more  frequently  impHcated  than  the  lower.  It  is  always  markedly 
increased  by  any  nervousness  or  agitation  of  mind,  and  is  frequently 
met  with  in  persons  in  a  weak,  nervous,  or  hysterical  condition.  It 
may  also  be  due  to  some  local  irritation,  as  an  inverted  lash,  slight 
inflammation  of  the  conjunctiva,  etc.  It  is  sometimes  observed  in  cases 
of  hypermetropia,  in  which  glasses  are  not  worn,  and  will  then  disappear 
with  the  removal  of  the  cause.  In  nervous  and  delicate  persons,  the 
general  health  should  be  attended  to,  an  aromatic  and  slightly  stimu- 
lating lotion  applied  to  the  lids,  and  the  eye-douche  be  used.  In  hyper- 
metropia, the  proper  glasses  should  be  ordered,  and  then  the  twitching 
will  soon  disappear. 

2  Y  2 


692  DISEASES   OF   THE   EYELIDS. 


12.— TRICHIASIS  AND  DISTICHIASIS. 

These  conditions  are  characterised  by  an  irregularity  in  the  growth 
and  direction  of  the  eyelashes,  which  are  more  or  less  inverted.  In 
trichiasis  the  lashes  are  irregular,  some  perhaps  having  a  natural 
position  and  appearance,  whilst  others  are  incurved,  thin,  pale,  strag- 
gling, and  stunted.  In  distichiasis,  there  are  two  distinct  rows  of 
lashes,  the  outer  being  in  the  usual  position,  the  inner  being  situated 
farther  back  and  turned  inwards.  The  double  arrangement  is,  how- 
ever, often  only  apparent,  being  due  to  a  thickening  and  stretching  of 
the  edge  of  the  lid,  and  a  consequent  alteration  in  the  direction  of  the 
hair  bulbs  and  the  cilia.  Both  trichiasis  and  distichiasis  may  affect  the 
whole  length  of  the  lid,  or  be  limited  to  a  certain  portion  or  portions 
of  it ;  and  if  the  malposition  only  involves  a  very  few,  colourless,  thin 
cilia,  it  may  readily  be  overlooked,  and  maintain  a  prolonged  and  very 
annoying  irritation  of  the  eye  and  lids. 

This  faulty  position  of  the  cilia  is  generally  accompanied,  or  soon 
followed,  by  a  certain  degree  of  inversion  of  the  eyelid  (entropium), 
and  perhaps  by  a  shortening  and  incurvation  of  the  tarsal  cartilage. 
But  in  the  simple  and  true  trichiasis  or  distichiasis  this  is  not  the  case, 
and  the  position  of  the  lid  and  the  condition  of  the  cartilage  are  perfectly 
normal. 

The  most  frequent  causes  of  these  conditions  are  long  continued 
and  severe  inflammations  of  the  conjunctiva  (purulent  and  granular 
ophthalmia,  etc.),  and  of  the  edge  of  the  lid  ;  in  which  the  hair  follicles 
have  undergone  inflammatory  and  suppurative  changes,  so  that  they 
are  either  destroyed,  or  their  functions  so  much  impaired,  that  the 
growth  of  the  lashes  is  injured,  and  they  become  weak,  stunted,  and 
distorted.  Ulcers  and  small  abscesses  at  the  roots  of  the  cilia,  or 
injuries  (burns,  cuts,  etc.)  of  the  edge  of  the  lid,  may  also  produce 
these  affections. 

The  irregular  growth  and  inversion  of  the  lashes,  even  although 
only  a  few  may  be  involved,  set  up  considerable  irritation  of  the  eye, 
which  becomes  watery,  red,  and  irritable,  the  patient  complaining  of  a 
constant  pricking  and  itching  in  it,  as  if  a  minute  foreign  body,  or  a 
little  sand  or  grit  were  lodged  beneath  the  lid.  If  the  affection  is 
allowed  to  continue,  the  symptoms  of  irritation  increase  in  severity, 
and  there  may  be  considerable  lachrymation  and  photophobia.  The 
constant  spasmodic  contraction  of  the  eyelids  causes  an  inversion  of 
the  edge  of  the  latter,  wliich  may  in  time  become  permanent,  so  that 
an  entropium  is  superadded  to  the  trichiasis.  After  a  time,  the  con- 
stant friction  of  the  inverted  or  stunted  lashes  asrainst  the  cornea  sets 


TRICHIASIS  AND  DISTICHIASIS.  693 

tip  a  superficial  corneitis,  and  a  more  or  less  severe  degree  of  panrrns 
will  sujjervene. 

The  treatment  of  distichiasis  and  trichiasis  must  vary  with  the 
extent  and  severity  of  the  disease.  If  only  a  few,  straggling  cilia  are 
misplaced,  their  repeated  evulsion  may  eventually  cure  the  affection. 
By  frequently  extracting  the  lashes,  we  may  in  time  succeed  in  causing 
an  atrophy  of  the  hair  bulbs,  and  thus  arrest  the  growth  of  the  cilia. 
Indeed,  many  patients  learn  to  do  this  very  well  for  themselves,  or  are 
satisfied  to  have  the  lashes  extracted  every  few  weeks  by  their  medical 
attendant.  If  the  trichiasis  is  confined  to  a  very  few  and  scattered 
lashes,  this  treatment  may  sufiice.  But  the  oft-repeated  evulsion  occa- 
sionally leads,  after  a  time,  to  a  certain  degree  of  irritability  of  the  eye, 
and  may  thus  become  a  source  of  annoyance  to  the  patient.  Sometimes, 
the  destruction  of  the  hair  follicles  by  the  application  of  liquor  potassaa 
also  proves  successful,  where  only  a  few  cilia  are  implicated.  A  horn 
spatula  having  been  inserted  beneath  the  eyelid,  and  the  edge  of  the 
latter  put  on  the  stretch  and  somewhat  everted,  so  that  the  row  of 
lashes  is  brought  well  into  view,  the  point  of  a  needle  (dipped  into 
liquor  potassse)  should  be  run  up  to  the  roots  of  the  distorted  lashes,  so 
as  to  reach  their  follicles ;  or  liquified  potassa  fusa  may  be  employed 
for  this  purpose  and  in  the  same  manner,  as  has  been  proposed  by 
Dr.  Williams.*  This  will  generally  soon  cause  their  destruction. 
Some  sui'geons  also  produce  the  latter  by  means  of  the  application  of 
a  strong  caustic  solution  {e.g.,  the  sulph-hydrate  of  calcium).  In  order 
that  it  may  not  extend  to  the  conjunctiva  or  the  cheek,  and  set  up 
considerable  inflammation,  the  surrounding  parts  should  be  smeared 
with  oil,  the  edge  of  the  lids  be  well  everted,  and  the  solution  very 
carefully  applied.  The  calcium  is  to  be  washed  away  with  a  sponge 
after  four  or  five  minutes.  But  if  a  considerable  extent  of  the  lid  is 
treated  in  this  manner,  a  very  unsightly  baldness  (madarosis)  will 
ensue.  And  hence  it  is  always  wiser  to  endeavour,  where  a  consider- 
able length  of  the  edge  of  the  lid  is  involved,  to  perform  some  opera- 
tion which  shall  prove  a  cure,  and  yet  preserve  the  eyelashes.  Very 
numerous  operations  have  been  proposed  for  the  cure  of  trichiasis, 
more  especially  when  combined,  as  is  generally  the  case,  with  entro- 
pium.  Some  of  these  consist  in  the  complete  excision  of  some  or  all 
of  the  eyelashes,  others  in  giving  the  latter  a  different  direction  but 
not  destroying  them. 

When  only  a  limited  number  of  lashes  are  misplaced,  the  following 
is  the  best  mode  of  excising  them. 

If  the  upper  lid  is  the  seat  of  the  disease,  Snellen's  modification  of 
Desmarres'  clamp.  Fig.  91,  should  be  used.     The  lower  blade  should  be 
inserted  beneath  the  upper  eyelid,  and  the  two  blades  then  screwed 
*  "  R.  L.  O.  n.  Rep.,"  iii,  219. 


694 


DISEASES  OF  THE  EYELIDS. 


down,  so  as  to  compress  the  eyelid  firmly  between  them  and   con- 
trol the  bleeding.     In  the  operations  for  slight,  partial  trichiasis,  it 

Fig.  91. 


is  not  so  necessary  to  use  this  instrument,  as  for  those  which  are  per- 
formed when  a  considerable  portion  of  the  lid  is  implicated.  An 
incision  is  then  to  be  made  with  a  small  scalpel  (or  with  a  broad  iridec- 
tomy knife)  at  the  edge  of  the  lid,  just  between  the  misplaced  lashes  and 
the  openings  of  the  Meibomian  ducts,  so  that  the  cilia  are  included  in 
the  anterior  portion  of  the  incision.  The  latter  is  to  extend  upwards 
to  about  3'",  and  its  length  should  include  all  the  distorted  lashes. 
Two  incisions  are  then  to  be  made  through  the  edge  of  the  lid  and  the 
skin,  these  incisions  meeting  at  the  centre,  so  as  to  form  two  sides  of  a 
triangle,  the  base  of  which  is  formed  by  the  lower  incision  along  the 
margin  of  the  Ud.  This  triangle,  which  includes  the  bulbs  of  the  mis- 
placed lashes,  should  then  be  removed.  The  lateral  incisions  may  also 
be  made  with  a  pair  of  curved  scissors,  one  point  of  which  is  to  be 
inserted  at  the  angles  of  the  longitudinal  wound.  The  lateral  edges 
of  the  incision  are  to  be  brought  together  with  fine  sutures. 

Herzenstein  has  devised  the  following  operation  for  trichiasis, 
which  appears  to  be  especially  applicable  to  the  partial  forms,  where 
only  a  few  cilia  are  implicated.  It  consists  in  the  insertion  of  a  thread, 
which  sets  up  considerable  irritation,  and  the  accompanying  suppui^a- 
tion  causes  the  destruction  of  the  follicles  of  the  displaced  cilia.  Dr. 
Herzenstein  performs  the  operation  in  the  following  manner : — He  enters 


TRICHIASIS  AND  DISTICHIASIS. 


695 


a  needle  (N,  ¥ig.  92),  carrying  a  fine  silken  thread,  at  tlae  edge  of  tlie 
lid  between  the  cilia  and  tlie  openings  of  the  Meibomian  ducts,  at  a 
(Fig.  92),  passes  it  along 

subcutaneously      in      a  Fig-  92. 

vertical  dii'ectiou,  and 
brings  it  out  at  b, 
slightly  above  the  mar- 
gin of  the  lid.  The  one 
thread  is  here  drawn 
through,  and  the  needle 
again  inserted  at  the 
same  opening,  h,  and 
passed  along  subcuta- 
neously, and  parallel  to 
the  margin  of  the  lid, 
to  the  extent  of  the  dis- 
torted lashes  (to  c).  The 

thread  is  here  again  drawn  through,  and  the  needle  re-inserted  at  the 
same  orifice,  c,  and  passed  down  vertically  to  make  its  way  out  at  a  point 
(d)  between  the  borders  of  the  margin  of  the  lid.  The  two  ends  of  the 
thread  are  then  firmly  tied,  and  permitted  to  cut  their  way  out.  Cold 
compresses  should  be  applied.  If  numerous,  little  yellow  spots  of 
suppui'ation  appear,  the  thread  should  be  at  once  removed.  He  has 
also  operated  successfully  in  cases  where  a  very  considerable  extent  of 
the  lid  was  affected.* 

When  a  considerable  portion  of  the  lashes  is  misplaced,  we  must 
remove  a  long  naiTOw  strip  of  the  edge  of  the  lid,  which  includes  these 
faulty  cilia,  or  even  "scalp"  the  whole  lid.  Snellen's  clamp  having  been 
applied,  an  incision  is  to  be  made  with  a  scalpel  or  cataract  knife 
along  the  free  edge  of  the  lid  between  the  eyelashes  and  the  opening  of 
the  Meibomian  glands,  so  as  to  split  the  cartilage  into  two,  and 
sufficiently  deep  to  pass  beyond  the  roots  of  the  lashes.  A  second 
incision  is  then  to  be  raade  on  the  external  surface  of  the  lid,  and  carried 
along,  and  parallel  to,  its  edge,  just  behind  the  row  of  lashes,  so  that  the 
two  incisions  meet,  and  the  strip  of  skin  and  integument,  containing  all 
the  faulty  lashes  and  theii'  roots,  is  then  to  be  excised.  This  operation 
may  be  partial  or  extend  nearly  to  the  whole  length  of  the  lid, 
according  to  the  extent  of  the  faulty  lashes.  On  completing  the 
excision,  the  part  should  be  sponged^  and  the  cartilage  be  closely 
examined,  to  discover  if  any  of  the  hair  bulbs  (which  appear  like 
minute  black  spots)  have  escaped,  in  which  case,  they  should  be 
excised,  otherwise  the  cilia  will,  of  course,  grow  again.  Sutures 
need  not  be  employed,  but  a  cold  wet  compress  should  be  applied. 
*  "A.  f.  0.,"xii,  1,76. 


696 


DISEASES   OF   THE  EYELIDS. 


The  above  operation  is  certainly  efficacious  in  curing  the  trichiasis, 
but  it  is  unsightly,  more  especially  in  the  upper  lid,  and  the  entii-e 
absence  of  the  eyelashes  and  their  protective  influence  may  give  rise  to  a 
good  deal  of  inflammation,  from  exposure  of  the  eye  to  external  irritants, 
such  as  dust,  etc.  However,  in  persons  who  are  careless  as  to  their 
personal  appearance,  and  are  anxious  to  be  quickly  and  effectually  cured 
of  the  disease,  this  operation  will  be  found  a  very  suitable  one.  But 
in  those  cases,  in  which  it  is  of  importance  to  preserve  the  eyelashes, 
and  simply  to  give  them  a  diff"erent  and  better  position,  so  that  in  place 
of  being  turned  in,  they  are  well  everted,  the  operation  of  transplanta- 
tion is  to  be  much  preferred.  Indeed,  I  almost  invariably  perform  it 
in  preference  to  that  of  scalping,  even  although  the  personal  appear- 
ance may  be  of  no  particular  importance.  The  two  following  are,  I 
think,  the  best  operations  for  transplantation. 

1.  Arlt's  modification  of  Jaesche's  operation.  As  this  is  a  tedious 
and  painful  proceeding,  the  patient  should  be  put  under  the  influence 
of  chloroform.  Snellen's  clamp  having  been  applied,  an  incision  is  to 
be  carried  along  the  free  edge  of  the  eyelid,  between  the  cilia  and 
the  openings  of  the  Meibomian  ducts,  and  reaching  to  a  depth  of 
about  2'",  care  being  taken  to  avoid  the  punctum.     In  this  way,  the 

free  edge  of  the  lid  will  be 
Fig.  93.  split  into  two  portions.     The 

anterior  containing  the  in- 
teguments, eyelashes,  and 
their  bulbs,  etc.,  and  the  pos- 
terior the  cartilage  and  the  ef- 
ferent ducts  of  the  Meibomian 
glands.  When  this  incision 
is  completed,  a  second  is  to  be 
carried  along  the  outer  sur- 
face of  the  lid,  about  1|-"'  or 
2'"  above  the  eyelashes,  and 
parallel  to  them.  This  incision  is  to  extend  through  the  skin  and 
the  orbicularis  down  to  the  cartilage,  and  be  of  sufficient  length  to 
pass  at  each  extremity  somewhat  beyond  the  first  incision.  In  the 
next  place,  a  third,  semi-circular  incision  is  to  be  made  from  one 
extremity  of  the  second  incision  to  the  other  (as  in  Fig.  93),  so  that 
a  semi-circular  portion  of  skin  is  included  within  it.  This  portion  of 
skin  is  then  to  be  very  carefully  dissected  away,  without  any  injury  of 
the  orbicularis.  The  size  of  the  flap  must  vary  with  the  amount  of 
eversion  which  we  desire;  in  simple  cases  of  trichiasis,  without  any 
entropium,  it  need  be  but  small.  When  this  has  been  done,  the  edges 
of  the  incisions  should  be  brought  together  by  fine  sutures.  The  effect 
of  this  shortening  of  the  skin  of  the  eyelid  will  be  to  roll  out  the  edge 


ENTROPIUM.  697 

of  the  lid  and  the  eyelashes,  which  can  be  the  more  effectually  done  as 
the  edge  of  the  lid  has  been  split  into  two,  and  the  external  portion  is 
thus  greatly  Hberated. 

I  have  found  this  operation  generally  very  successful,  but  it  must  be 
confessed  that  it  does  occasionally  fail  in  two  ways.  1st.  The  change 
in  the  position  of  the  faulty  cilia,  which  are  situated  near  the  extremi- 
ties of  the  incision,  may  not  be  sufficient.  2nd.  The  nutrition  of  the 
narrow  bridge  containing  the  eyelashes  may  be  here  and  there  impaired, 
leading  to  a  partial  slough  and  loss  of  the  lashes  at  this  point.  To 
obviate  these  ill  results,  and  yet  to  preserve  all  the  advantages  of 
this  method  of  operating,  Von  Graefe  has  devised  the  following  modifi- 
cation :* — 

2.  Von  Graefe's  operation  (vide  Fig.  94).     He  makes  two  vertical 
incisions  4'"  in  length,  which  pass  upwards  from  the  anterior  edge  of 
the  lid  through  the  skin  and  orbicularis,  and 
form  the  lateral  margins  of  the  portion  of  the  Fig.  94. 

lid  which  is  to  be  transplanted.  Hence,  if  the 
trichiasis  is  complete,  and  extends  to  the  whole 
length  of  the  eyelid,  the  external  vertical  in- 
cision will  be  at  the  outer  commissure,  the 
inner  at  the  upper  lachrymal  punctum  (wliich 
should  be  preserved  intact).  In  the  next 
place,  an  incision  is  to  be  carried  along  the 
free  edge  of  the  lid  between  the  cilia  and  the 
Meibomian  ducts,  just  as  in  Arlt's  operation. 

The  lashes  can  now  be  well  everted,  and.  in  order  to  assist  still  further 
in  maintaining  this  position,  an  oval  portion  of  skin  may  be  excised 
(vide  Fig.  94),  or  this  may  be  effected  by  the  application  of  two  or 
three  vertical  sutures,  without  excision. 

13.— ENTROPIUM. 

In  this  condition,  the  free  edge  of  the  eyelid  is  more  or  less  inverted, 
so  that  the  eyelashes  are  turned  in  and  sweep  against  the  eyeball.  The 
entropium  may  be  either  partial  or  complete,  and  be  limited  to  one  eyelid, 
or  affect  both.  We  must  distinguish  two  principal  forms  of  the  disease. 
1.  The  spasmodic  or  acute  entropium,  and  2,  the  chronic  entropium, 
which  is  caused  by  inflammatory  changes  in  the  conjunctiva  and  car- 
tilage. 

The  spasmodic  entropium  is  acute  in  character,  and  occui's  chiefly 

in  elderly  persons  (hence  it  is  often  also  termed  senile  entropium),  the 

skin  of  whose  eyelids  is  very  lax,  and  who  have  perhaps  had  their  eyes 

bandaged  up  for  some  length  of  time  ;  thus,  it  is  often  observed  if  a  firm 

*  "A.  f.  0.,"x,  2,  226. 


I 


698  DISEASES   OF   THE  EYELIDS. 

bandage  or  pad  has  been  worn,  either  on  account  of  some  operation  on 
the  eye,  or  for  some  inflammatory  affection.  Indeed  the  photophobia 
and  long  continued  spasm  of  the  lid  attendant  upon  the  latter,  may 
give  rise  to  entropium  by  the  spasmodic  contraction  of  the  orbicularis, 
which  causes  the  edge  of  the  lid  to  roll  in,  more  especially  if  the  skin 
of  the  lid  is  very  abundant  and  lax.  In  this  form  of  spasmodic  entro- 
pium, we  observe  that  the  lashes  have  become  tucked  in  towards  the 
eyeball,  and  are  quite  hidden  from  view,  the  margin  of  the  lid  being 
rolled  in  upon  itself,  and  presenting  its  smooth,  rounded  edge  upwards. 
On  gently  drawing  back  the  eyelid  into  its  normal  position,  we  notice 
that  it  looks,  perhaps,  quite  healthy,  or  only  slightly  swollen  and  red ; 
but  its  edge  is  not  sore  or  notched,  and  the  eyelashes  are  perfectly 
regular  and  well  developed,  being  neither  distorted  nor  dwarfed.  The 
lid  can  be  temporarily  retained  in  its  natural  position,  but  very  soon  it 
rolls  in  again,  especially  if  the  patient  should  wink.  This  form  of 
entropium  is  particularly  met  with  in  the  lower  eyelid,  but  may  also 
affect  the  upper. 

In  the  chronic  entropium  the  appearances  are  very  different,  for  on 
everting  the  edge  of  the  lid,  we  generally  find  it  inflamed,  excoriated, 
contracted,  and  notched.  The  eyelashes  are  sparse  and  irregular  in 
their  growth,  showing  the  characters  of  distichiasis  or  trichiasis,  and 
being  dwarfed  and  stunted.  Instead  of  the  eyelid  presenting  folds  of 
super-abundant,  lax  skin,  it  often  looks  rather  shortened  and  tightly 
stretched,  the  cartilage  being  contracted  and  incurved;  and  on  eversion  of 
the  eyelid  (which  is  frequently  performed  with  difficulty),  the  conjunctiva 
shows  the  remains  of  inflammatory,  and  often  deeply  marked  cicatricial 
changes.  The  length  of  the  palpebral  opening  (from  angle  to  angle) 
is  frequently  considerably  diminished  in  size,  so  that  the  eye  looks 
smaller  and  sunken.  The  induration  and  contraction  of  the  cartilage  are 
often  very  marked,  and  it  may  be  shortened  horizontally  or  transversely. 
These  changes  in  the  cartilage  are  especially  observed  as  a  consequence 
of  severe  and  long  standing  granular  ophthalmia.  This  form  of  entro- 
pium is  generally  caused  by  various  inflammations  of  the  conjunctiva 
and  the  edge  of  the  lid,  more  especially  if  there  is  much  photophobia, 
and,  in  consequence  of  this,  severe  blepharospasm.  Long  persistent 
distichiasis  or  trichiasis  may  also,  as  has  been  already  stated,  give  rise 
to  a  certain  degree  of  entropium.  The  latter  may  likewise  occur  when 
the  eyeball  is  atrophied  and  shrunken,  so  that  it  no  longer  fills  out  the 
orbit  and  sustains  the  lids,  which  consequently  show  a  tendency  to  be- 
come rolled  in.  Entropium  may  also  be  of  traumatic  origin.  Thus, 
bums,  scalds,  injuries  from  lime,  or  wounds  of  the  inner  surface  of  the 
eyelid,  may  produce  it,  by  causing  a  destruction  and  cicatricial  con- 
traction of  the  conjunctival  and  subconjunctival  tissue.  In  such  cases, 
Bymblepharon  often  co-exists. 


ENTROPIUM.  699 

The  presence  of  entropinm  genei'ally  soon  sets  np  great  irritation  of 
the  eye,  producing  photophobia,  lachrymation,  and  blepharospasm. 
Subsequently,  superficial  corneitis  supervenes,  and  a  more  or  less  dense 
pannus  may  be  formed,  leading  to  still  graver  complications  if  the 
inversion  of  the  lids  is  not  cured.  In  some  instances,  however,  even  a 
tolerably  severe  degree  of  entropium  may  exist  for  some  time  w^ithout 
setting  up  much  irritation. 

The  treatment  of  entropium  must  vary  according  to  the  nature  and 
extent  of  the  disease.  In  the  slight  and  recent  cases  of  spasmodic  or 
senile  entropium  (especially  of  the  lower  lid),  it  may  suffice  to  replace 
the  Hd  in  its  normal  position,  and  then  to  paint  its  external  surface  with 
collodion.*  This  will  dry  at  once,  and  prevent  the  lid  from  again 
invertipig.  The  collodion  must  be  renewed  every  two  or  three  days. 
But  if  the  entropium  is  too  considerable  in  degree  for  this  mode  of 
treatment,  a  narrow  horizontal  fold  of  skin,  running  jiarallel  and  close 
to  the  edge  of  the  lid,  and  a  portion  of  orbicularis  should  be  removed. 
A  fold  of  skin  of  the  requisite  size  having  been  caught  up  between  the 
branches  of  the  entropium  forceps,  is  to  be  excised  by  a  few  rapid  snips 
of  the  scissors,  and  then  a  portion  of  the  orbicularis  should,  if  necessary, 
be  also  removed.  Before  beginning  the  excision  of  the  skin,  we  should 
see  what  effect  the  pinching  up  of  the  fold  between  the  forceps  has 
upon  the  position  of  the  lid.  If  it  does  not  evert  the  latter  sufficiently, 
a  larger  fold  must  be  seized;  if  its  effect  is  too  great,  the  size  of  the 
fold  must  be  diminished.  As  a  rule,  no  sutures  will  be  required,  but 
a  light  pad  and  bandage  should  be  appHed,  when  the  bleeding  has 
ceased.  It  has  been  also  recommended  to  excise  one  or  more  small  oval 
portions  of  integument  in  a  vertical  direction,  the  edges  being  united 
by  fine  sutures.  The  removal  of  a  horizontal  fold  of  skin  is,  however, 
in  my  experience,  to  be  preferred. 

As  the  palpebral  aperture  is  frequently  considerably  shortened  in 
chronic  cases  of  entropium,  so  that  the  eye  looks  very  small,  much 
benefit  is  often  derived  from  slitting  up  the  outer  canthus  (cantho- 
plasty).  Indeed,  in  some  cases  this  proceeding  may  suffice  to  cure  the 
inversion  of  the  hds ;  or  this  operation  should  be  combined  with  one  of 
those  for  entropium.  The  outer  canthus  may  be  divided  with  a  bistoury 
or  with  a  pair  of  strong  scissors.  In  the  former  case,  a  director  should 
be  inti'oduced  beneath  the  outer  commissure,  and  the  latter  divided 
upon  it  with  the  bistoury  to  the  requisite  extent,  the  incision  running 
in  a  horizontal  direction  and  being  in  the  prolongation  of  the  palpebral 
aperture.  If  scissors  are  employed,  one  blade  should  be  passed  behind 
the  outer  canthus,  the  other  in  front,  and  the  commissure  be  divided 
with  one  sharp  cut.  An  assistant  is  then  to  stretch  the  incision  in  a 
vertical  direction,  so  as  to  cause  it  to  gape.  The  conjunctival  surface 
*  Vide  Mr.  Bovrman's  paper,  "  Braithwaite'e  Retrospect,"  1851. 


700 


DISEASES   OF   THE   EYELIDS. 


Pig.  95. 


Fig.  96. 


of  the  incision  is  to  be  united  at  one  or  more  points  to  the  skin  by  a  fine 
suture,  in  order  to  prevent  union  taking  place.  One  suture  should  be 
applied  at  the  upper  angle,  another  at  the  lower,  and,  if  advisable,  a 
third  may  be  inserted  at  the  outer  extremity  of  the  wound.  This  opera- 
tion of  canthoplasty  is  often  also  indicated  in  cases  of  anchyloble- 
pharon  or  symblepharon. 

Von  Graefe*  strongly  recommends  the 
following  operation  for  spasmodic  entro- 
pium.  He  makes  a  horizontal  incision 
(Fig.  95)  through  the  skin,  parallel  to  the 
edge  of  the  lower  lid  and  about  1^'"  from 
its  anterior  margin,  the  extremities  of  the 
incision  running  up  to  within  1'"  or  2'"  of 
a  vertical  line  passing  through  each  com- 
missure. He  then  removes  a  triangular 
portion  of  skin  (A),  the  two  lateral  flaps, 
B  and  G,  are  somewhat  dissected  up  and 
united  by  two  or  three  fine  horizontal 
sutures.  The  horizontal  wound  is  left  to 
cicatrize.  He  varies  the  height  and  breadth 
of  the  triangle,  according  to  the  degree  of 
relaxation  of  this  portion  of  the  lid.  The 
height  is  of  little  consequence,  but  the 
breadth  may  have  to  vary  from  3'"  to  5'". 
If  we  desire  to  gain  a  still  more  considerable  efiect,  the  vertical  incisions 
may  be  made  of  the  shape  represented  in  Fig.  96. 

If,  together  with  a  spasmodic  entropium  of  the  upper  lid,  the  carti- 
lage is  contracted,  Von  Graefe,  after  having  made  the  horizontal  incision 
and  removed  a  triangular  portion  of  skin  (Fig.  97),  carries  a  hori- 
zontal incision  through  the  fibres  of  the  orbicularis  muscle  close  to  the 
edge  of  the  lid,  and  pushes  them  up  so  as  to  expose  the  external  surface 

of  the  cartilage.  A  triangular  portion  of 
the  latter  (B)  is  then  to  be  removed,  the 
position  of  the  triangle  being  the  reverse  of 
that  in  the  skin,  so  that  the  base  of  the 
triangle  (varying  in  extent  from  2^'"  to 
3'")  reaches  close  to  the  upper  edge  of 
the  cartilage,  and  its  apex  lies  close  to  the 
margin  of  the  lid.  The  whole  thickness  of 
the  cartilage  should  be  removed,  so  that 
only  the  conjunctiva  remains.  The  middle 
suture  (/3  /3)  should  pass  through  the  edges 
of  the  incision  in  the  cartilage.  It  is  generally  necessary  to  combine 
*  "  A.  f.  O.,"  X,  2,  222. 


I 


ENTROPIUM.  701 

cantlioplasty  witli  this  operation,  as  it  may  otherwise  diminish  the  size 
of  the  palpebral  aperture  too  much. 

In  those  cases  of  entropium  in  which  the  tarsal  cartilage  is  unaf- 
fected and  has  retained  its  normal  curvature,  the  operations  of  trans- 
plantation of  Arlt  or  Von  Graefe  (page  697),  will  be  found  very 
serviceable.  But  if  the  entropium  is  considerable,  a  larger  portion  of 
skin  should  be  removed  (together  with  some  of  the  fibres  of  the  orbicu- 
laris) than  in  the  case  of  simple  trichiasis. 

The  following  operation  of  Pagenstecher*  will  also  be  found  an 
exceedingly  good  one.  He  commences  by  dividing  the  external  com- 
missure of  the  lids  to  such  an  extent,  that  the  wound  in  the  conjunctiva 
equals  fi'om  2'"  to  3'",  and  that  in  the  skin  from  3'"  to  4'".  By  mode- 
rately stretching  the  edges  of  the  incision  downwards,  the  horizontal 
wound  is  changed  into  a  vertical  one,  and  the  opposed  surfaces  of  skin 
and  conjunctiva  are  then  to  be  united  by  sutures.  By  this  proceeding 
the  palpebral  aperture  is  enlarged,  a  slight  ectropium  is  produced,  and 
the  action  of  the  orbicularis  is  diminished  by  the  interposition  of  the 
conjunctiva  between  its  fibres.  The  lid  being  everted,  he  next  inserts 
several  ligatures,  more  especially  at  those  points  where  the  cilia  have 
a  faulty  position.  For  this  purpose,  the  lax  skin  of  the  lid  and  the 
fibres  of  the  orbicularis  are  to  be  lifted  up  into  a  horizontal  fold  mth 
a  pair  of  forceps,  and  a  curved  needle  (armed  with  a  strong,  waxed 
thi-ead)  passed  tkrough  the  base  of  the  fold,  quite  close  to  the  external 
surface  of  the  tarsal  cartilage.  The  point  of  the  needle  is  then  to  be 
brought  out  at  the  edge  of  the  lid,  slightly  to  the  outer  side  of  the 
apertures  of  the  Meibomian  ducts.  The  ligature  is  to  be  firmly  tied 
and  allowed  to  suppurate  out,  which  generally  occurs  in  from  6  to  10 
days.  As  a  rule,  two  or  three  ligatures  will  suffice  to  produce  a  con- 
siderable eversion  of  the  margin  of  the  lid.  The  effect  of  each  suture 
can  be  calculated  according  to  the  width  of  the  fold  of  skin  which  is 
lifted  up.  The  advantages  which  Pagenstecher  claims  for  this  opera- 
tion are: — 1.  That  the  pressure  which  the  lid  exercises  iipon  the  eye- 
ball is  diminished  by  the  widening  of  the  palpebral  aperture ;  2,  the 
prevention  of  the  cilia  coming  into  contact  with  the  cornea ;  3,  the 
eyelashes  are  preserved  and  their  normal  growth  promoted.  The  little 
scars  left  by  the  sutures  very  soon  disappear,  without  leaving  any  trace 
behind  them.f  Cold  water  dressing  should  be  employed  in  order  to 
alleviate  the  inflammation,  which  is  sometimes  severe,  and  a  bandage 
should  be  applied  so  as  to  keep  the  parts  quiet.  In  some  cases,  the 
sutures  may  be  removed  before  they  slough  out. 

Snellenf  recommends  a  ligature  to  be  inserted  in  the   following 

*  "Klinische  Beobachtungen,"  1861;  also  "  Compte-Renclu  du  Congres 
d'Ophtbalmologic,"  1802,  p.  241. 

t  "  Coinpte-Rendu  du  Congres  d'Oplithahnologie,"  1862,  p.  236. 


I 


702  DISEASES  OP  THE  EYELIDS. 

manner: — The  lid  being  very  much  everted,  he  passes  two  needles 
(attached  to  each  end  of  a  silken  tkread)  from  within  outwards  through 
the  whole  thickness  of  the  lid,  so  that  the  one  needle  pierces  the  upper 
margin  of  the  cartilage,  and  the  other  passes  a  little  above  this  edge.  The 
needles  are  then  re-introduced  at  the  points  of  exit,  passed  down  to 
the  anterior  surface  of  the  cartilage  and  along  it,  beneath  the  orbicu- 
laris, towards  the  edge  of  the  eyelid,  being  brought  out  just  in  front  of 
the  lashes,  close  to  each  other,  at  about  a  distance  of  two  millimetres. 
The  upper  edge  of  the  tarsal  cartilage  is  thus  enclosed  in  a  sling,  and 
in  tying  the  thi-eads  near  the  ciliary  border,  we  evert  the  edge  of  the 
lid  and  draw  it  upwards.  The  thread  may  be  removed  about  the  third 
day,  care  being  taken  that  no  portion  of  it  remains  behind,  otherwise 
sloughing  may  occur.  It  must  be  admitted,  however,  that  ligatures 
alone,  often  prove  but  of  shght,  or  only  temporary  benefit. 

When  the  entropium  is  paired  with  contraction  and  incurvation  of 
the  tarsal  cartilage,  operations  which  simply  act  upon  the  position  of 
the  lid  by  the  removal  of  a  portion  of  skin,  and  perhaps  some  of  the 
fibres  of  the  orbicularis,  no  longer  suffice;  but  we  must  then  also  remove 
a  portion  of  the  cartilage,  so  that  the  cicatrization  may  cause  a  contrac- 
tion of  the  outer  portion  of  the  cartilage,  and  thus  counteract  the  incur- 
vation. 

For  this  purpose  Mr.  Streatfeild*  devised  his  operation  of  "  grooving 
the  cartilage,"  which  answers  very  well  when  the  latter  is  simply 
incurved  without  being  contracted.  He  performs  the  operation  thus  : — 
"  The  lid  is  held  with  Desmarres'  forceps,  the  flat  blade  passed  under 
the  Hd,  and  the  ring  fixed  upon  the  skin,  so  as  to  make  it  tense  and 
expose  the  edge  of  the  hd.  An  incision  with  a  scalpel  is  made  of  the 
desired  length,  just  through  the  skin,  along  the  palpebral  margin,  at  a 
distance  of  a  line  or  less,  so  as  to  expose  but  not  to  divide  the  roots  of 
the  lashes  ;  and  thenjust  beyond  them  the  incision  is  continued  down  to 
the  cartilage  (the  extremities  of  this  wound  are  inclined  towards  the 
edge  of  the  lid)  ;  a  second  incision,  farther  from  the  palpebral  margin, 
is  made  at  once  down  to  the  cartilage  in  a  similar  direction  to  the  first ; 
and  at  a  distance  of  a  line  or  more,  and  joining  it  at  both  extremities ; 
these  two  incisions  are  then  continued  deeply  into  the  cartilage  in  an 
oblique  direction  towards  each  other.  With  a  pair  of  forceps  the 
strip  to  be  excised  is  seized  and  detached  with  the  scalpel." 

I  have  succeeded  in  curing  severe  cases  of  entropium  with  marked 
contraction  and  incurvation  of  the  cartilage  by  a  combination  of  Arlt 
and  Streatfeild' s  method.  The  first  steps  of  the  operation  are  identical 
with  those  of  Arlt's  (p.  696)  ;  but  after  the  removal  of  the  oval  portion 
of  skin,  I  make  a  longitudinal  incision  through  the  fibres  of  the  orbi- 
cularis down  to  the  cartilage.  The  latter  being  well  exposed,  I  make 
*  "  E.  L.  O.  H.  Eep.,"  i,  121. 


ECTROPIUM.  703 

two  longitudinal  incisions  (inclining  towards  each  other)  in  it,  nearly- 
down  to  its  inner  surface.  The  incisions  should  slope  so  much  that 
they  meet  near  the  posterior  surface  of  the  cartilage,  and  thus  include 
a  wedge-shaped  strip  of  the  latter,  the  base  of  the  wedge  being  turned 
towards  the  skin,  and  the  apex  towards  the  conjunctiva.  This 
strip  of  cartilage  is  then  to  be  excised  with  the  scalpel.  The  size  of 
tliis  strip  will  depend  upon  the  degree  and  extent  of  the  incurvation  and 
contraction  of  the  cartilage.  The  edges  of  the  incision  in  the  skin 
should  be  neatly  brought  together  by  sutures,  which  are  to  be  passed 
somewhat  deeply,  so  as  to  include  a  portion  of  the  orbicularis,  but  need 
not  be  passed  tlirough  the  cartilage. 


14.— ECTROPIUM. 

In  this  condition,  the  eyelid  is  more  or  less  everted  and  its  con- 
junctival surface  exposed.  The  degree  of  ectropium  varies  greatly, 
being  in  some  cases  so  slight  that  the  edge  of  the  lid  is  but  a  very  little 
turned  out  and  di'ooping,  whereas  in  others,  the  whole  eyelid  is  everted 
and  its  lining  membrane  apparent. 

Slight  degrees  of  ectropium  are  often  seen  in  elderly  people,  more 
especially  if  they  are  affected  with  a  chronic  inflammation  and  thicken- 
ing of  the  conjunctiva  and  edge  of  the  lids.  This,  together  with  a 
certain  degree  of  atrophy  and  relaxation  of  the  orbicularis,  causes  the 
edge  of  the  lid  (especially  the  loAver)  to  become  somewhat  everted  and 
drooping,  so  that  its  margin  is  no  longer  applied  to  the  eyeball,  but 
sinks  away  from  it.  In  consequence  of  this  slight  eversion,  the  punc- 
tum  lacrymale  is  no  longer  turned  in  towards  the  eyeball,  but  is  erect 
or  everted.  The  tears,  instead  of  being  carried  off  through  the  cana- 
liculus, collect  at  the  inner  corner  of  the  eye,  so  that  the  eye  appears 
to  be  always  moist  and  swimming  in  tears  ;  the  latter  flow  over  the  edge 
of  the  lid,  and  thus  mamtain  and  increase  any  existing  excoriation  or 
inflammation  of  its  margin.  Severe  inflammations  of  the  conjunctiva 
(especially  purulent  and  granular  ophthalmia)  are  frequently  the  cause 
of  ectropium,  particularly  if  they  are  accompanied  by  great  swelling  and 
hypertrophy  of  the  conjunctiva,  and  by  such  considerable  chemosis,  that 
the  latter  protrudes  perhaps  between  the  lids.  For  if  the  cedematous 
infiltration  and  swelling  of  the  lid  subside,  but  those  of  the  conjunctiva 
continue,  the  lid  is  apt  to  become  everted  by  the  action  of  the  orbicu- 
laris ;  being  assisted  in  this  by  the  hypertrophy  of  the  conjunctiva,  to 
which  the  external  portion  of  the  lid  can  ofier  no  counterpoise,  and  also 
by  the  great  degi'ee  of  chemosis.  If  such  an  eversion  occurs,  and  is 
not  at  once  replaced,  the  compression  of  the  cartilage  and  of  the  upper 
portion  of  the  lid  soon  j^roduce  great  strangulation  and  a  serous  and 


704  DISEASES  OF   THE   EYELIDS. 

haemorrhagic  infiltration  of  the  lid,  whicli  greatly  increase  the  swelling. 
Hence  the  tumour,  as  Mackenzie  remarks,  is  occasioned  in  a  great 
measure  by  strangulation,  like  the  swelling  in  paraphimosis.  We  not 
unfrequently  observe  such  cases  of  ectropium  in  children  suffering  from 
purulent  ophthalmia,  in  whom  the  lid  has  become  accidentally  everted 
during  the  application  of  local  remedies,  etc. ;  and  instead  of  having 
been  at  once  replaced,  some  time,  perhaps  several  days,  has  elapsed 
before  medical  aid  was  sought.  The  strangulation  is  greatly  increased 
in  children  by  their  violent  fits  of  crying  and  struggling.  In  chronic 
cases  of  purulent  and  granular  ophthalmia,  the  conjunctiva  is  not  only 
swollen  and  hypertrophied,  but  the  cartilage  becomes  relaxed  and 
stretched,  so  that  it  no  longer  maintains  the  proper  curvature  and 
position  of  the  lid,  but  assists  materially  in  the  production  of  the 
ectropium.  The  lid  becomes  at  the  same  time  elongated ;  indeed, 
ectropium  seldom  exists  for  any  length  of  time  without  causing  a 
certain,  often  considerable,  increase  in  the  length  of  the  lid. 

Paralysis  of  the  portio  dura  also  causes  ectropium  (especially  of 
the  lower  lid)  and  lagophthalmos.  Intra-orbital  tumours,  abscess  of  the 
orbit,  etc.,  often  produce  eversion  of  the  lid,  on  account  of  the  exoph- 
thalmos to  which  they  give  rise. 

But  the  most  frequent  cause  of  ectropium  is  found  in  the  presence 
of  cicatrices,  excoriations,  etc.,  in  the  vicinity  of  the  edges  of  the  lids, 
for  by  their  contraction,  during  cicatrization,  the  margin  of  the  lid 
becomes  more  or  less  everted.  Thus,  in  long- continued  excoriation  or 
eczematous  inflammation  of  the  edge  of  the  lid  and  its  vicinity,  we  find 
that  a  contraction  of  the  skin  takes  place,  and  the  lid  becomes  some- 
what everted.  This  can  often  be  observed  in  cases  of  inflammation  of 
the  conjunctiva  and  cornea,  accompanied  by  severe  lachrymation.  The 
edge  of  the  lid  becomes  swollen  and  inflamed,  its  margin  rounded,  the 
eyelashes  stretched  and  displaced,  and  the  punctum  everted  and  perhaps 
obliterated.  Various  injuries  to  the  external  surface  of  the  lids  or  the 
integuments  in  their  vicinity,  such  as  burns,  scalds,  wounds,  etc.,  which 
produce  loss  of  substance,  may  give  rise  by  theii'  cicatrization  to  more 
or  less  considerable  ectropium. 

Caries  of  the  orbit,  more  especially  at  its  outer  and  lower  margin, 
is  a  fruitful  source  of  very  severe  and  obstinate  forms  of  ectro- 
pium ;  for  the  caries  is  frequently  accompanied  by  the  destruction  of  a 
considerable  portion  of  the  substance  of  the  lid  and  of  the  cartilage, 
which  may  be  implicated  in  the  cicatrix  and  adherent  to  the  bone. 
Thus,  we  sometimes  find  the  smooth  surface  of  the  lid  di^awn  at  one 
point  into  a  small  funnel-shaped  aperture,  which  extends  deeply  down 
as  far  as  the  bone,  to  which  its  apex  is  adherent.  Abscess  of  the 
frontal  sinus,  which  perforates  by  a  small  opening  through  the  upper 
portion  of  the  lid,  may  be  followed  by  an  adhesion  of  the  lid  to  the 


ECTROPIUM.  705 

aperture  in  the  bone,  and  a  considerable  degree  of  ectropium.  In  cases 
of  ectropium  of  the  upper  lid,  due  to  caries,  we  may  often  notice  (as 
Mackenzie  points  out)  the  vicarious  action  of  the  lower  hd,  which 
becomes  somewhat  raised,  so  as  to  accommodate  itself  to  the  deficiency 
of  the  upper. 

Ectropium  generally  soon  produces  a  chronic  inflammation  of  the 
conjunctiva  and  cornea,  on  account  of  the  exposure  of  the  eye  to  the 
irritating  influences  of  the  atmosphere,  and  of  foreign  substances,  such 
as  dust,  etc.  After  a  time,  the  conjunctiva  becomes  thickened,  swollen, 
and  desiccated,  its  epithelial  layer  hypertrophied  and  roughened,  and 
at  length  xerophthalmia  may  be  produced,  the  conjunctiva  and 
cartilage  undergoing  atrophic  changes.  The  cornea  becomes  inflamed, 
pannus  supervenes,  or  deep  ulcers  are  formed,  which  may  lead  to  exten- 
sive perforation  and  all  its  dangerous  consequences,  such  as  staphy- 
loma, or  even  atrophy  of  the  eyeball.  We  often  find,  however,  that  the 
efiect  of  the  ectropium  upon  the  eye  is  but  inconsiderable,  and  is  not 
followed  by  any  marked  inflammation  of  the  conjunctiva  or  cornea. 
This  is  due  to  the  fact,  that  the  eyeball  is  rolled  upwards,  and  is  thus 
protected  by  the  upper  lid  (the  wrinkling  and  contraction  of  the  brow 
often  assisting  in  this),  which  thus  guards  it  against  external  irritants. 
Hence,  we  sometimes  find  that  patients  apply  to  us  for  treatment  of 
the  ectropium  far  less  on  account  of  the  inflammatory  or  other  afiec- 
tions,  than  for  the  sake  of  having  their  personal  appearance  improved, 
which  is  rendered  extremely  unsightly  from  the  exposure  of  the  red, 
fleshy  conjunctiva.  In  consequence  of  the  ectropium  and  the  mal- 
position of  the  puncta,  the  tears  cannot  enter  the  latter,  but  flow  over 
the  cheek,  and  from  the  lachrymal  sac  being  in  a  constant  state  of 
emptiness  and  non-use,  it  may  in  time  shrink  and  become  permanently 
diminished  in  size  (Weber),*  its  walls  being  thinned  and  atrophied. 

In  the  eversion  consequent  upon  inflammation  and  hypertrophy  of 
the  conjunctiva,  the  lid  should  be  at  once  replaced,  if  we  see  the  case 
sufficiently  early,  and  should  be  retained  in  its  proper  position  by  a 
compress  bandage.  Directions  should  also  be  given  to  the  attendants 
in  cases  of  purulent  ophthalmia,  etc.,  more  especially  in  children, 
immediately  to  replace  the  lid  if  it  becomes  everted  during  the  appli- 
cation of  topical  remedies.  If  this  treatment  does  not  suflice,  and  there 
is  great  hypertrophy  and  proliferation  of  the  conjunctiva,  the  surface  of 
the  latter  should  be  touched  with  mitigated  nitrate  of  silver,  the  effect 
of  which  is,  however,  to  be  at  once  neutrahzed  with  salt  and  water. 
The  conjunctiva  is  then  to  be  freely  scarified,  which  will  generally 
cause  a  considerable  diminution  in  the  size  of  the  lid.  In  some  cases  it 
is,  however,  necessary  to  excise  a  more  or  less  considerable  portion  of 

*  "  A.  f.  O.,"  viii,  1,  95. 

2  Z 


706  DISEASES  OF   THE  EYELIDS. 

the  swollen  and  hypertropliied  conjunctiva.  If  these  remedies  fail,  we 
must  have  recourse  to  operative  interference ;  but  I  may  mention  that 
the  operations  proposed  and  practised  at  different  times  are  far  too 
numerous  to  be  entered  upon  here,  and  I  shall  consequently  confine 
myself  to  a  description  of  those  which  have  been  found  to  be  the  most 
useful  and  successful.  I  must  state,  however,  that  no  very  definite  or 
precise  rules  can  be  laid  down  as  to  the  exact  method  of  operating,  for 
we  constantly  meet  with  cases  of  ectropium  so  variable  in  degree  and 
extent,  that  we  are  obliged  to  modify  and  alter  the  raode  of  operating, 
in  order  to  adapt  it  to  the  exigencies  of  each  individual  case. 

In  the  above  form  of  ectropium,  as  well  as  in  the  senile,  the  best 
treatment  is  the  diminution  of  the  palpebral  aperture  by  the  opera- 
tion of  tarsoraphia,  more  especially  if  there  is  a  certain  degree  of 
lengthening  of  the  eyelid.  Before  proceeding  to  operate,  the  surgeon 
should  take  the  outer  edges  of  the  lids  between  his  forefinger  and 
thumb,  and  draw  them  somewhat  out  towards  the  external  canthus,  and 
then  approximate  them  towards  each  other  at  this  point,  in  order  that 
he  may  be  able  accurately  to  estimate  the  extent  to  which  the  palpebral 
aperture  should  be  narrowed.  The  effect  which  this  narrowing  has  upon 
the  edge  of  the  everted  lid  should  likewise  be  noted,  as  also  the  fact 
whether  the  lid  has  to  be  a  little  raised  or  depressed,  in  order  to  bring 
it  into  a  proper  position.  If  the  puncta  are  erect  or  everted,  they  should 
be  slit  up,  so  as  to  facihtate  the  entrance  of  the  tears  into  the  sac. 

Tarsoraphia,  which  was  first  devised  by  Walther,  is  to  be  performed 
as  follows  : — The  operator  having  inserted  a  horn  or  ivory  spatula 
between  the  lids  at  the  outer  canthus,  makes  an  incision  through  the 
skin  and  connective  tissue  parallel  to  the  edge  of  the  upper  lid,  and 
about  three-quarters  of  a  line  from  its  margin.  This  incision  is  to  be 
commenced  at  the  outer  canthus,  and  carried  along  the  edge  of  the  lid  to 
a  distance  of  from  1^'"  to  3'"  ;  it  is  then  to  be  carried  vertically  down  to, 
and  through,  the  anterior  edge  of  the  lid.  This  portion  of  the  lid, 
including  its  cilia,  is  then  to  be  completely  excised  from  this  point  to 
the  outer  canthus,  care  being  taken  that  the  hair  follicles  are  not 
divided  obliquely,  but  entirely  removed,  otherwise,  they  will  grow  again. 
The  same  proceeding  is  then  to  be  repeated  in  the  lower  lid,  so  that  the 
two  raw  surfaces  of  the  edges  of  the  lids  can  be  accurately  applied  to 
each  other,  and  united  by  two  or  three  sutures.  In  order  still  more  to 
facilitate  the  union,  and  to  give  the  lashes  a  more  perfect  and  favour- 
able inclination.  Von  Graefe*  has  modified  the  operation  in  the  follow- 
ing manner.  He  carries  on  horizontally  the  inner  portion  of  the  vertical 
incision  (which  has  been  made  perpendicularly  through  the  edge  of  the 
lid)  to  the  extent  of  about  1'"  or  1^'"  towards  the  nose,  along  the  pos- 

*  "  A.  f.  O.,"  iv,  2,  201. 


ECTROPIUM.  707 

tenor  border  of  the  margin  of  the  lid,  and  pares  the  latter  by  removing 
a  small  slip  of  conjunctiva.  This  is  to  be  done  in  each  lid,  the  cilia 
being  of  course  left  at  the  outer  portion  of  this  part  of  the  lid.  In 
those  cases  in  which  there  is  a  considerable  elongation  of  the  edge  of 
the  lower  lid,  as  well  as  of  its  cartilage,  an  unsightly  pucker  or  fold  is 
apt  to  be  produced  by  the  sutures  at  the  outer  can  thus.  To  obviate 
this,  a  triangular  portion  of  the  substance  of  the  lower  lid  should  be 
excised  near  the  outer  commissure,  the  base  of  the  triangle  being 
turned  towards  the  edge  of  the  lid.  The  operation  of  tarsoraphia  will 
also  be  found  very  useful  in  lagophthalmos  due  to  paralysis  of  the 
portio  dura,  as  well  as  in  that  which  is  sometimes  noticed  after  the  old 
squint  operation. 

For  the  senile  or  spastic  forms  of  ectropium,  tarsoraphia  will 
be  found  greatly  preferable  to  the  operation  of  Adams,  which  consists  in 
the  removal  of  a  triangular,  Y-shaped  piece  from  the  whole  thickness 
of  the  lid,  the  base  of  the  triangle  being  turned  towards  the  margin  of 
the  latter,  and  the  apex  towards  the  cheek.  The  edges  of  the  wound 
are  then  to  be  brought  accurately  together  by  sutures,  one  of  which 
should  be  inserted  close  to  the  margin  of  the  tarsus,  so  that  the 
lips  of  the  wound  may  be  brought  very  closely  together  at  this 
point.  The  chief  disadvantage  of  this  operation  is,  that  when  it  is 
done  near  the  central  part  of  the  lid,  it  shortens  the  edge  of  the  latter 
without  elevating  it  at  the  outer  canthus,  hence  it  is  closely  pressed 
against  the  eyeball,  which  may,  moreover,  be  somewhat  irritated  by  the 
pucker  or  fold  to  which  the  cicatrix  gives  rise.  If  this  operation  is 
adopted,  it  should,  therefore,  be  performed  close  to  the  outer  canthus, 
as  this  tends  to  elevate  the  edge  of  the  lid  at  this  point. 

We  have  now  to  turn  our  attention  to  those  cases  in  which  a  partial 
or  complete  ectropium  is  due  to  a  cicatrix,  which  is  situated  at  a  short 
distance  from  the  edge  of  the  lid,  and  causes  eversion  of  the  latter  by 
traction. 

Very  numerous  operations  have  been  devised  to  remedy  this  defect, 
of  which  I  shall  only  mention  those  of  Wharton  Jones  (sometimes 
also  termed  Samson's  operation),  Dieffenbach,  and  Von  Graefe,  for 
they  are,  I  think,  the  most  generally  useful  and  successful. 

Mr.  Wharton  Joneses  operation  is  to  be  performed  in  the  following 
manner  :* — "  The  eyelid  is  set  free  by  incisions  made  in  such  a  way,  that 
when  the  eyeUd  is  brought  back  into  its  natural  position,  the  gap  which 
is  left  may  be  closed  by  bringing  its  edges  together  by  suture,  and  thus 
obtaining  immediate  union.  Unlike  the  Celsian  operation,  the  narrower 
the  cicatrice  the  more  secure  the  result.  The  flap  of  skin  embraced  by 
the  incisions  is  not  separated  from  the  subjacent  parts ;  but  advantage 

*  Tide  Mr.  Wharton  Jones,  "  Treatise  on  Ophthalmic  Medicine  and  Surgery," 
p.  627. 

2  z  2 


708 


DISEASES   OF   THE  EYELIDS. 


Fig.  98. 


After  Stellwag. 


Fig.  99. 


being  taken  of  the  looseness  of  tlie  subcutaneous  cellular  tissue,  the 

flap  is  pressed  downwards,*  and 
thus  the  eyelid  is  set  free.  The 
success  of  this  operation  depends 
very  much  on  the  looseness  of  the 
cellular  tissue.  For  some  days 
before  the  operation,  therefore, 
the  skin  should  be  moved  up  and 
down,  in  order  to  render  the  cel- 
lular tissue  more  yielding." 

In  Figs.  98  and  99,  the  method 
of  performing  this  operation  upon 
the  lower  eyelid  is  illustrated.  A 
horn  spatula  having  been  inserted 
beneath  the  lower  lid,  so  as  to 
render  this  tense,  two  straight  in- 
cisions are  to  be  made  from  the 
edge  of  the  lid,  in  such  a  manner 
that  they  converge  towards  each 
other,  and  meet  at  such  a  dis- 
tance below  the  lid,  that  the  cica- 
trix is  completely  included  within 
the  triangular  flap  thus  formed. 
The  flap  is  then  to  be  pressed 
upwards,  so  as  to  bring  the  edge 
of  the  lid  into  its  normal  position, 
and  all  the  opposing  bridles  of 
cellular  tissue  are  to  be  divided, 
without  however  dissecting  off 
the  flap  from  the  subjacent  parts,  except  perhaps  very  slightly  at  the 
periphery.  The  edges  of  the  wound  existing  below  the  apex  of  the  flap 
are  next  to  be  closely  united  by  two  common  or  twisted  sutures  (Fig.  99), 
and  then  the  two  edges  of  the  flap  are  to  be  accurately  united  by 
sutures  at  each  side  to  the  opposite  margin  of  the  wound.  If  it  be 
necessary  somewhat  to  shorten  the  edge  of  the  lid,  tarsoraphia  may  be 
united  with  this  operation.  The  above  method  of  operating  is  espe- 
cially indicated  in  those  cases  of  ectropium,  in  which  the  shape  and 
form  of  the  lid  are  but  little  changed,  its  margin  beiug  chiefly  elon- 
gated. 

Diefienbach  devised  the  following  operation  for   eversion   of  the 


After  Stellwag. 


*  Mr.  Jones  is  here  desci'ibing  the  method  in  which  the  operation  is  to  be  per- 
formed on  the  upper  lid ;  in  the  lower  lid,  of  course,  the  flap  would  be  pressed 
upwards,  and  the  natural  position  of  the  edge  of  the  lid  would  be  thus  regained. 


ECTROPIUM.  709 

lower  lid,  due  to  a  cicatrix  situated  at  a  short  distance  from  it.  The 
cicatrix  is  to  be  included  within  a  triangular  flap,  the  base  of  which  is 
to  be  turned  towards  the  margin  of  the  lid,  the  apex  to  the  cheek. 
This  triangular  portion  is  then  to  be  removed,  and  the  incision,  which 
represents  the  base  of  the  triangle,  is  to  be  prolonged  horizontally  on 
each  side  to  a  short  distance,  in  order  to  facilitate  the  approximation  of 
the  lateral  eda'es  of  the  triang-le,  which  should  be  raised  from  the  sub- 
jacent  parts  by  a  few  incisions  with  the  scalpel.  The  two  lateral  inci- 
sions of  the  triangle  are  to  be  imited  by  fine  sutures,  and  then  the 
horizontal  incision,  on  each  side  of  the  base  of  the  triangle,  is  also  to 
be  brought  together  by  sutures. 

Von  Graefe  has  lately  introduced  the  following  method  of  operating 
for  the  severer  cases  of  ectropium  of  the  lower  lid,  more  especially 
those  which  are  the  result  of  chronic  blepharo-adenitis.  He  naakes  a 
horizontal  incision  just  behind  the  edge  of  the  lid,  in  the  intermarginal 
space,  from  the  lower  punctum  to  the  outer  canthus.  From  the  extremi- 
ties of  this  line  (Fig.  100)  two  incisions  are  then  to  descend  vertically 
down  the  cheek,  for  a  distance  of  from  8'"  to  10'".  The  square  flap  A  is 
next  to  be  dissected  up,  and,  if  necessary,  ^. 

somewhat  raised  subcutaneously  beyond 
the  lower  extremities  of  the  vertical  inci- 
sions. The  flap  is  then  to  be  seized  at  its 
upper  edge  by  two  pairs  of  broad  forceps, 
and  forcibly  stretched  upwards,  and  main- 
tained in  this  position  by  sutm'cs,  which 
are  to  be  applied  first  at  the  vertical  in- 
cisions, commencing  at  their  lower  ex- 
tremity. The  two  upper  angles,  which  now  project  considerably  above 
the  upper  margin  of  the  opposite  edge  of  the  wound,  should  next  be 
sufficiently  bevelled  ofi*,  and  this  is  best  done  by  making  a  somewhat 
bent  incision  {B  B)  whose  acute  angle  G  is  then  to  be  drawn  up  and 
united  to  D.  The  efi"ect  of  this  bent  incision  B  B  is  twofold,  viz.,  it 
shortens  the  edge  of  the  lid,  and  elevates  the  flap.  The  closer  to  the 
edge  of  the  lid  that  the  point  G  is  brought,  the  less  does  it  elevate  the 
flap,  but  the  more  does  it  shorten  the  edge  of  the  lid.  Whereas,  the 
closer  the  point  G  hes  to  the  vertical  incision,  the  more  is  the  flap  ele- 
vated, and  the  less  is  the  edge  of  the  lid  shortened.  The  more  exact 
measurements  as  to  the  size  of  the  incisions,  etc.,  can  only  be  deter- 
mined during  the  performance  of  the  operation,  more  especially  the 
adaptation  of  the  flap  in  its  new  position,  as  we  must  shape  and  modify 
them  according  to  cu'cumstances.  Indeed  this  holds  good  in  all  plastic 
operations.  Finally,  the  horizontal  wound  is  to  be  closed  with  sutures, 
and  in  such  a  manner  that  the  latter  include  broad  portions  of  skin,  but 
only  narrow  ones  of  conjunctiva ;  as  this  is  more  favourable  for  the 


710  DISEASES   OF   THE  EYELIDS. 

subsequent  fastening'  of  the  flap,  for  the  difierent  threads  of  the 
sutures  are  to  be  tolerably  tightly  fixed  to  the  forehead.  A  firm  com- 
press bandage  is  to  be  appHed  during  the  first  twenty-four  hours. 
Von  Graefe  has  found  this  operation  much  more  successful  than  that  of 
Diefienbach.* 

In  those  instances  of  ectropium  in  which  extensive  cicatrices  involve 
a  considerable  portion,  or  even  the  whole  thickness  of  the  lid,  as  often 
occurs  in  caries  or  necrosis  of  the  bone,  or  in  cases  of  cancer,  etc., 
of  the  lids,  it  may  be  necessary  corapletely  to  excise  the  affected  portion, 
and  to  fill  up  the  wound  by  transplanting  a  flap  taken  from  the  adjacent 
integuments.  This  operation  of  making  a  new  eyelid  is  termed  MepTta- 
roplastij,  and  very  numerous  modifications  of  it  have  been  from  time  to 
time  devised  ;  Dieffenbach  and  Fricke  having  been  amongst  the  first  to 
practise  it.  The  flaj?  is  sometimes  taken  from  the  temple  and  forehead, 
in  other  cases,  from  the  cheek  or  side  of  the  nose,  according  to  the  size 
and  position  of  the  cicatrix  or  growth  which  is  to  be  excised.  The  flap 
has  even  been  formed  from  the  back  of  the  hand.f  I  shall,  however, 
only  describe  a  few  of  the  more  important  and  most  generally  successful 
modes  of  operating,  which  will  suffice  to  illustrate  the  principles  that 
should  guide  us,  but  the  details  of  which  must  be  modified  and  altered 
according  to  the  exigencies  of  special  cases.  There  are,  however,  a 
few  points  which  apply  to  all  these  cases  of  blepharoplasty,  and  atten- 
tion to  which,  greatly  increases  the  chance  of  a  favourable  result. 
Thus,  the  size  of  the  flap  should  always  be  larger  than  the  wound  into , 
which  it  is  to  be  fitted,  in  order  that  this  may  be  completely  filled  up, 
and  its  edges  and  those  of  the  flap  be  readily  united  without  any  undue 
stretching  ;  a  certain  degree  of  latitude  being  also  allowed  for  a  little 
shrinking  or  contraction  of  the  flap.  Care  must  likewise  be  taken  that 
the  surrounding  skin  is  not  too  much  stretched,  when  the  flap  is 
fastened  in  its  new  position ;  hence,  if  any  undue  tension  exists,  a  few 
superflcial  incisions  should  be  made  in  the  skin  near  the  base  of  the  flap, 
so  as  somewhat  to  liberate  it.  The  base  of  the  flap  should  always  be 
made  sufficiently  broad  to  maintain  the  vitality  of  the  transplanted 
poi'tion,  which  is  otherwise  prone  to  slough.  This  vitality  may,  how- 
ever, be  also  impaired  by  the  unhealthy  condition  of  the  skin  from 
which  the  flap  is  taken  ;  by  its  being  too  firmly  pressed  against  the  bone 
by  a  very  tight  compress  bandage ;  or,  on  the  other  hand,  by  its  not 
being  kept  in  sufficiently  close  contact.  The  prospect  of  the  success  of 
the  operation  is  always  best,  when  the  integuments  from  which  the  flap 
is  taken  are  quite  healthy,  and  are  free  from  all  cicatricial  or  inflam- 
raatory  changes. 

*  "  A.  f.  O.,"  X,  2,  229.  t  Vitle  Wharton  Jones,  loc.  cit.,  p.  638. 


ECTROPIUM. 


711 


In  Fig.  101  is  illustrated  the  method  of  excising  a  large  cicatrix  of 
the  upper  Hd,  which  has  produced  extensive  ectropium.     The  cicatrix 


FiK.  101. 


After  Stellwag. 


is  to  be  included  within  two  horizontal  incisions,  which  converge 
towards  each  other  at  the  inner  (nasal)  side,  but  diverge  and  descend 
somewhat  at  the  temple.  The  diseased  portion  of  the  lid  is  then  to  be 
carefully  dissected  away  from  the  subjacent  tissue,  so  as  thoroughly  to 
liberate  the  lid,  which  is  then  to  be  drawn  into  its  normal  position. 
The  extent  and  shape  of  the  wound  which  is  thus  made,  are  to  be 
estimated  with  as  much  accuracy  as  possible,  and  a  corresponding  flap 
(A,  Fig.  101)  is  then  to  be  dissected  from  the  skin  of  the  temple.  For 
reasons  stated  above,  the  size  of  this  flap  should,  however,  be  somewhat 
larger  than  the  wound  into  which  it  is  to  be  fitted.  When  the  flap  has 
been  carefully  dissected  off",  so  that  only  its  base  remains  standing,  it  is 
to  be  twisted  somewhat  upon  itself,  fitted  into  the  wound,  and  carefully 
fastened  there  by  numerous  fine  sutui'es  ;  the  incisions  in  the  temple 
being  closed  in  the  same  way. 

In  Fig.  102  is  shown  the  method  of  fastening  a  flap  which  has  been 
dissected  out  from  the  temple  into  a  wound  in  the  lower  eyelid. 

Diefienbach  made  three  incisions,  which  formed  an  equilateral 
triangle,  and  included  the  cicatrix ;  the  one  incision  being  carried 
parallel  to,  and  somewhat,  below  the  margin  of  the  lower  lid,  Fig.  103. 
He  then  excised  the  portion  included  within  the  triangle,  and  next 
dissected  an  oblong  flap  of  skin  (Fig.  103  A)  from  the  parts  imme- 
diately adjacent  to  the  wound,  and  shifted  it  laterally  into  the  latter, 
retaining  it  in  this  position  by  sutures  (Fig.  104). 


712 


DISEASES  OF   THE  EYELIDS. 


Fig.  102. 


After  Stellwag. 


Fig.  103. 


After  Stellwag. 


ECTROPIUM. 
Fig.  104. 


713 


After  Stellwag. 

If  the  margin  of  the  lid  is  implicated  in  the  disease,  it  must  also  be 
included  in  the  part  which  is  excised ;  and  the  upper,  horizontal  in- 
cision of  the  new  flap  should  then  be  made  somewhat  longer,  so  that 
this  portion  of  the  flap  may  form  the  edge  of  the  lid. 

Knapp  has  described*  an  ingenious  modification  of  blepharoplasty, 
performed  by  him  in  a  case  in  which  a  cancerous  tumour  occupied  the 
inner  two-thirds  of  the  lower  lid  (including  its  edge),  extending  some- 
what beyond  the  inner  angle  of  the  eye,  and  involving  the  skin  of  the 
nose  to  an  extent  of  from  2'"  to  3'".  As  the  flap  is  apt  to  contract 
when  it  is  made  with  its  base  downwards,  and  may  thus  give  rise  to 
ectropium,  Dr.  Knapp,  at  the  suggestion  of  Dr.  Fritz  Pagenstecher, 
operated  in  the  following  manner : — He  included  the  tumour  between 
straight  incisions  (which  were  carried  well  into  the  healthy  tissue). 
After  the  morbid  growth  had  been  thoroughly  removed,  he  proloncred 
the  internal  horizontal  incisions  towards  the  nose,  and  thus  prepared  a 
square,  horizontal  flap  at  this  point.  He  then  made  (in  the  prolonga- 
tion of  the  palpebral  aperture)  an  incision  from  the  outer  canthus 
slightly  upwards  into  the  skin  of  the  temple ;  and  next  a  second  in- 
cision, which  was  at  first  a  straight  prolongation  of  the  lower  edge  of 
the  wound,  but  was  then  somewhat  arched  downwards  on  to  the  cheek 
the  concavity  looking  downwards.  The  long  flap  thus  formed,  and 
which  increased  considerably  in  width  towards  its  base,  was  then  dis- 

*  "A.  f.  O.,"  xiii,  1,  183. 


714  DISEASES   OF   THE  EYELIDS. 

sected  off  from  tlie  subjacent  tissue,  drawn  forwards,  and  its  inner 
angle  united  by  twisted  sutures  to  tbe  vertical  edge  of  the  nasal  flap. 
Both  flaps,  though  rather  tightly  stretched,  entirely  covered  the  wound, 
and  formed  a  very  successful  artificial  lid.  The  external  fourth  of  the 
latter,  which  had  remained  standing,  now  formed  the  most  internal 
portion.  The  edges  of  the  wound  were  then  carefully  united  by  very 
numerous  sutures,  and  a  compress  bandage  applied  for  48  hours. 
Perfect  union  resulted,  and  the  patient  was  discharged  14  days  after- 
wards, completely  cured.  The  palpebral  aperture  was  slightly  (about 
2'")  diminished  in  length,  but  could  be  easily  and  perfectly  opened  and 
closed  by  the  action  of  the  upper  lid.  The  lower  lid  was  closely  applied 
to  the  globe,  and  Knapp  states  that  this  was  one  of  the  most  successful 
cases  of  blepharoplasty  with  which  he  has  met.  In  cases  in  which  we 
unite  the  opposite  edges  of  two  flaps,  care  must  always  be  taken  to 
allow  a  sufiicient  amount  of  skin,  so  as  to  permit  of  a  certain  degree  of 
contraction  and  gaping  of  the  edges  of  the  flaps,  in  case  that  they 
should  not  unite  by  first  intention,  which  is  not  unlikely  to  occur. 

In  those  cases,  in  which  cicatrices  or  cancerous  growths  imphcate 
the  inner  or  outer  canthus,  and  to  a  small  extent  the  opposite  edges  of 
the  two  Hds,  the  flap  which  is  to  cover  the  wound  may  be  taken  from 
the  skin  of  the  nose  or  the  temple,  according  to  the  situation  of  the 
disease.  In  such  instances,  the  following  operation,  devised  by  Hasner, 
will  be  found  useful : — If  the  morbid  growth  be  situated  at  the  outer 
canthus,  and  implicates  to  a  certain  extent  the  edges  of  the  upper  and 
lower  lid,  the  tumour  is  to  be  included  above  and  below  between  two 
elliptical  incisions,  which  should  be  laid  well  in  the  healthy  integument. 
The  liue  of  junction  of  these  two  incisions  should  then  be  slightly 
prolonged  outwards,  and  a  suflB.ciently  large  flap  be  excised  from  the 
temple.  The  upper  extremity  of  this  flap  is  to  be  bifurcated,  so  as 
to  fit  easily  into  the  wound  made  in  the  edges  of  the  lid  at  the  outer 
canthus.  If  the  disease  is  situated  at  the  inner  canthus,  the  flap  should 
be  taken  from  the  side  of  the  nose. 

If  the  cicatricial  adhesions  are  narrow  and  not  very  firm,  it  may 
suffice  to  divide  them  subcutaneously,  and  thus  to  liberate  the  lid,  and 
allow  it  to  assume  its  normal  position, 

15._INJURIES,  WOimDS,  ETC.,  OF  THE  EYELIDS. 

Ecchjmosis  of  the  eyelids  is  of  frequent  occurrence,  being  chiefly  the 
consequence  of  a  severe  blow  or  fall  upon  the  eye,  and  is  hence  often 
met  with  in  pugilistic  encounters.  It  is  due  to  a  sanguineous  effusion 
into  the  areolar  tissue  of  the  eyelids,  which  gives  rise  to  a  dark,  livid 
discoloration,  commonly  termed  a  "  black-eye."  As  a  rule,  it  occurs 
within  a  few  hours  after  the  accident ;   it  may,  however,  come  on  at 


INJURIES,   WOUNDS,   ETC.,   OF   THE   EYELIDS.  715 

once,  the  discoloration  extending  from  the  eyelids  to  the  neighbour- 
ing parts.  These  facts  distinguish  this  form  of  ecchymosis  from  that 
which  is  due  to  a  counter-fracture  of  the  orbit,  for  then  the  reverse 
obtains,  the  discoloration  shows  itself  after  a  much  longer  interval,  and 
gradually  extends  to  the  eyelids.  Together  with  the  effusion  of  blood 
into  the  areolar  tissue  of  the  lids,  there  is  often  much  serous  infiltration 
and  swelling  of  the  latter  and  of  the  surrounding  parts,  the  lids  being 
perhaps  so  swollen  that  the  eye  is  firmly  closed.  The  discoloration  is 
at  first  dark  and  livid,  but  gradually  undergoes  various  changes  of  tint, 
turning  bluish-red,  green,  yellow,  etc.  A  black  eye  generally  disappears 
in  two  or  three  weeks'  time,  but  the  absorption  of  blood  may  be  accele- 
rated by  various  local  remedies.  Directly  after  the  injury,  compresses 
of  Hnt  dipped  in  ice-cold  water  should  be  applied,  and  very  frequently 
changed,  being  retained  in  position  by  a  firm  bandage.  This  application 
of  a  cold  compress  tends  greatly  to  limit  the  effusion  of  blood.  The 
absorption  of  the  latter  is  subsequently  much  hastened  by  the  con- 
tinuous application  of  a  fu-m  bandage,  together  with  which  an 
evaporating  lotion  should  be  employed.  Of  the  two,  the  bandage  will, 
however,  be  found  to  render  the  greater  service  in  accelerating  the 
absorption.  The  tincture  of  arnica  has  long  enjoyed  a  great  and 
special  reputation  for  curing  black  eyes.  It  should  be  employed  as  a 
lotion  (Tr.  Arnicte.  Mont.  5ij?  ad.  Aq.  Dist.,  or  Mist.  Camphor  3iv).  A 
compress  of  lint  is  to  be  soaked  in  this,  and  applied  to  the  lids  by  a 
firm  bandage.  The  following  formula  recommended  by  Mr.  Lawson  is 
also  a  very  good  one  : — 1^  Tr.  Ai-nic.  Mont.  5iv ;  Liq.  Ammon.  Acet.  3J  ; 
Sp.  Rosism.  5iv;  Mist.  Camph.  ad  5'^iii.  M.  f  lotio.  A  poultice  of 
black  bryony-root  is  likewise  much  in  vogue  amongst  the  public.  The 
swollen  parts  should  never  be  pricked  or  punctured,  as  this  tends  to 
produce  suppuration  and  erysipelas. 

JVounds  of  the  eyelids  vary  in  danger  according  to  their  situation 
and  extent,  and  according  to  the  fact  whether  they  are  simply  incised, 
or  are  punctured,  and  accompanied  perhaps  by  considerable  bruising 
and  contusion  of  the  parts.  If  the  incision  is  superficial  and  horizontal, 
and  has  only  divided  the  skin  and  a  few  of  the  fibres  of  the  obicularis, 
it  will  soon  heal  by  first  intention,  if  the  edges  of  the  wound  are  brought 
together  by  sutures  and  strips  of  plaster,  and  little,  if  any,  mark  mil 
be  left  behind.  But  when  the  wound  is  extensive  and  has  penetrated 
deeply  into  the  upper  lid,  implicating  perhaps  the  cartilage,  and 
dividing  the  fibres  of  the  levator  palpebrse,  its  consequences  are  much 
more  serious.  For  not  only  may  it  produce  a  considerable  degree  of 
ptosis,  but,  on  account  of  the  suppuration  which  may  supeivene,  con- 
traction and  shrinking  of  the  integuments  may  ensue,  and  give  rise  to 
a  severe  and  obstinate  ectropium.  If  the  cut  is  vertical,  it  may  divide 
the  tarsal  edge  of  the  lid,  splittuig  it  up  and  laying  it  open  to  a  more  or 


716  DISEASES   OF   THE   EYELIDS. 

less  considerable  extent,  thus  giving  rise  to  an  unsightly  gap  or  colo- 
boma.  If  the  rent  is  situated  near  the  inner  angle  of  the  eye,  it  may 
divide  the  canahculus,  and  tear  it  away  from  the  punctum  lacryraale. 
In  a  small  punctured  wound,  the  danger  is  but  slight,  if  it  is  confined  to 
the  eyelid  and  has  not  extended  into  the  orbit  or  injured  the  eyeball, 
otherwise,  it  may  produce  more  or  less  severe  orbital  cellulitis. ;  or,  if  the 
globe  has  been  injured,  serious  consequences  may  arise,  and  the  eye  be 
perhaps  completely  lost.  If  the  wound  or  tear  in  the  eyeHd  has  been 
accompanied  by  severe  contusion  of  the  parts,  there  is  always  much 
danger  of  suppuration  or  even  of  sloughing  setting  in.  Wounds  of  the 
eyelids  implicating  the  infra- orbital  nerve  have  been  noticed  to  produce 
amaurosis,  which  was  termed  sympathetic.  The  cases  of  this  kind 
which  have  been  narrated,  occurred,  however,  before  the  discovery  of 
the  ophthalmoscope,  and  hence  the  true  condition  of  the  fundus  oculi 
was  not  known. 

Wounds  of  the  skin  of  the  eyelids  should  be  brought  accurately 
together  with  fine  sutures  and  strips  of  plaster,  the  part  being  kept 
cool  and  at  rest  by  the  application  of  a  moist  compress  and  a  bandage. 
Even  where  the  wound  extends  deeply  into  the  tissue  of  the  eyelid,  and 
is  accompanied  by  much  bruising,  it  is  better  to  unite  its  edges  by 
sutures  than  to  leave  it  to  heal  by  granulation,  as  this  will  produce  a 
more  or  less  considerable  loss  of  substance,  contraction  of  the  integu- 
ments, and  very  probably  ectropium.  If  the  tarsal  edge  has  been 
divided  by  a  vertical  cut,  the  edges  of  the  gap  should  be  very  carefully 
brought  together,  and  maintained  in  accurate  apposition  by  the  insertion 
of  one  or  more  twisted  sutures.  One  suture  should  always  be  applied 
as  close  as  possible  to  the  edge  of  the  lid,  so  that  the  margin  of  the 
latter  may  become  closely  and  accurately  united.  The  edges  of  the 
gap  may,  if  necessary,  be  pared ;  the  needle  should  be  a  very  fine  one, 
and  should  be  inserted  through  the  cartilage.  If  the  canahculus  has 
been  divided,  its  opening  should  be  searched  for,  and  a  director  (Fig. 
85,  p.  611)  should  be  inserted,  and  the  canaliculus  be  slit  open  into  the 
sac,  with  a  cataract  knife. 

The  eyelids  are  often  also  injured  by  burns  or  scalds  from  hot  seeth- 
ing fluid,  the  flame  of  a  candle,  etc.,  the  explosion  of  gunpowder,  or 
the  action  of  strong  caustic  fluids.  If  the  edges  of  the  lids  are  severely 
injured,  these  may  become  adherent,  and  a  more  or  less  extensive 
anchyloblepharon  be  produced,  or  symblepharon  may  ensue,  if  the  con- 
junctiva has  been  implicated  in  the  injury.  Moreover,  a  very  severe 
and  obstinate  form  of  ectropium  often  ensues  upon  burns  of  the  lids, 
on  account  of  the  shrinking  and  contraction  of  the  skin  which  ac- 
company and  supervene  upon  the  cicatrization.  This  is  especially 
observed  in  the  lower  lid.  If  the  injury  is  so  extensive  that  httle  is 
left  of  the  eyelids  except  the  cartilage  and  the  conjunctiva,  the  ectro- 


INJURIES,   WOUNDS,   ETC.,   OF  THE  EYELIDS.  717 

pium  and  consequent  lagoplithalmos  are  so  great,  that  severe  inflamma- 
tion of  the  cornea  and  other  structures  of  the  eye  supervenes,  and  the 
latter  is  generally  soon  destroyed. 

In  slight  cases  of  scalds  or  burns  of  the  eyelids  in  which  the  cutis 
is  not  destroyed,  cold  water  dressing  should  be  apphed  and  constantly 
renewed  for  the  first  24  or  36  hours.  If  a  blister  forms,  this  should  be 
pricked  and  the  serum  allowed  to  escape,  the  water  dressing  being  then 
re-applied.  If  the  injui'y  has  been  so  severe  that  the  skin  is  destroyed, 
simple  cerate  dressing  should  be  applied,  and  great  care  be  taken  that 
the  lid  is  kept  upon  the  stretch  during  the  period  of  cicatrization,  in 
order  that  new  skin  may  be  formed,  and  ectropium  be  thus  avoided.  A 
bandage  should,  therefore,  be  so  appHed  as  to  keep  the  Ud  upon  the 
stretch,  and  the  patient  should  not  be  allowed  to  use  his  eyes  until 
complete  cicatrization  has  taken  place. 

The  eyelids  often  become  greatly  inflamed  and  swollen  from  the 
stings  of  insects,  such  as  bees,  gnats,  etc.  The  sting  should  be  removed 
as  soon  as  possible,  and  cold  water  dressing,  or  evaporating  lotions  be 
prescribed. 

Amongst  the  congenital  malformations  of  the  eye,  we  sometimes 
meet  with  epicanthus  and  coloboma  of  the  eyelid. 

Epicanthihs  consists  in  the  presence  of  a  crescentic  fold  of  skin, 
which  passes  from  the  nose  to  the  eyebrow,  and  overlaps  and  hides,  to  a 
greater  or  less  extent,  the  inner  canthus.  If  it  is  considerably  developed 
it  is  very  unsightly,  and  it  may  be  necessary  to  cure  it  by  operative 
interference.  But  we  should  wait  with  an  operation  until  the  child  gets 
older,  for  it  is  often  found  that  the  deformity  gradually  disappears,  as  the 
bones  of  the  nose  become  more  developed  and  the  latter  more  prominent. 
If  this  should  not,  however,  occur,  an  elliptical  fold  of  skin  (the  size  of 
which  must  vary  with  the  amount  of  efiect  which  we  desire  to  produce) 
is  to  be  excised  from  the  upper  portion  of  the  nose.  The  edges  of  the 
wound  should  be  somewhat  dissected  up,  so  that  they  may  be  the  more 
readily  approximated,  and  the  lips  of  the  wound  closed  with  sutures. 

Coloboma  or  fissui'e  of  the  eyelid  is  a  congenital  deformity,  which 
is  but  of  rare  occuiTence.  It  is  sometimes  associated  with  cleft  palate, 
hare-lip,  coloboma  of  the  iris  and  choroid,  and  other  arrests  of  develop- 
ment. The  fissure  may  be  confined  to  one  eyelid,  or  be  present  in  both  ; 
or  again,  a  double  cleft  may  exist,  the  two  fissures  being,  perhaps,  close 
to  each  other,  and  connected  by  a  small  intervening  bridge.  To  cure 
this  condition,  the  edges  of  the  coloboma  should  be  pared,  and  then 
accurately  brought  together  by  fine  twisted  sutures,  which  should  pass 
through  the  cartilage,  the  one  suture  being  quite  closely  applied  to  the 
free  edge  of  the  hd,  so  that  the  lips  of  the  cleft  may  here  be  very  evenly 
and  accurately  united. 


EXPLANATION   OF   THE   PLATES. 


PLATE  I. 

Figs.    1    and   2. 

The  Normal  Fundus  Oculi  (vide  p.  305). 

In  Fig.  1  (wliicli  is  taken  from  a  person  with  black  hair  and  a  dark 
hrown  iris)  the  optic  nerve  entrance  appears  circular,  and  of  a  yellowish 
white  tint.  The  blood-vessels  emerge  somewhat  to  the  left  of  the  centre 
of  the  disc,  which  is  here  of  a  deeper  white.  The  paler  vessels  are  the 
retinal  arteries,  the  darker  ones  the  veins.  They  pass  over  the  disc  to 
the  retina,  where  they  course  and  divide  in  different  directions,  chiefly 
upwards,  downwards,  and  towards  the  left.  At  some  little  distance  to 
the  right  of,  and  slightly  below,  the  disc,  is  noticed  a  large  dark-red 
spot,  with  a  small  white  dot  in  the  centre.  This  is  the  macula  lutea,  or 
yellow  spot,  with  its  foramen  centrale.  It  will  be  observed  that  the 
vessels  course  round  the  yellow  spot,  leaving  it  free.  The  fine  grey  film 
in  the  region  of  the  disc  and  the  yellow  spot  is  due  to  the  reflex  yielded 
by  the  retina ;  it  is  only  observable  in  dark  eyes,  and  is  consequently 
altogether  absent  in  Fig.  2.  The  fundus  of  the  eye  is  of  a  rich  dark-red 
tint,  and  only  the  retinal  vessels  are  apparent,  those  of  the  choroid  being 
hidden  by  the  density  of  the  pigment  in  the  epithehal  layer  and  stroma 
of  the  choroid. 


In  Fig.  2  (taken  from  the  eye  of  a  person  -fldth  very  light  hair  and  a 
blue  iris)  the  appearances  are  quite  different.  The  disc  is  of  a  more 
rosy  tint,  the  retinal  vessels,  although  very  distinct,  are  less  markedly 
so  than  on  the  darker  background  of  Fig.  1.  The  region  of  the  yellow 
spot  is  of  a  bright  red  colour,  and  the  foramen  centrale  appears  in  the 
form  of  a  little  light  circle.  But  the  greatest  difference  is  noticed  in 
the  pale,  brilliantly  red  colour  of  the  fundus,  and  the  distinctness  with 
which  the  finest  branches  of  the  choroidal  vessels  can  be  traced.  The 
ciliary  arteries  enter  in  the  region  of  the  yellow  spot,  and,  running 
towards  the  periphery,  ramify  in  various  directions,  and  partly  pass 
over  directly  into  the  larger  branches  of  the  vasa  vorticosa,  situated  at 
the  equator  of  the  eye. 


Platrl. 


r.tterLiebreJch'!.  Atla;; 


Berlki/vVij.ckeJmarin  k  Sijhne  (H  Porschi  lith. 


720  EXPLANATION  OF  THE  PLATES. 


PLATE  II. 

Fig.  3. 

Sderotico-choroiditis  Posterior  (Staphyloma  Posticum)  p.  427. 

This  figure  illustrates  the  appearances  presented  by  an  extensive 
sclerotico- choroiditis  posterior.  Towards  the  oater  side  of  the  disc  is 
observed  a  large  white  figure,  over  which  the  retinal  vessels  appear  to 
run  a  somewhat  straighter  course,  and  to  be  rather  more  numerous  and 
distinct.  The  disc  is  oval,  and  its  shortest  diameter  (in  this  case  the 
horizontal)  shows  the  direction  in  which  the  ectasia  (bulging)  is  situated. 
In  the  vicinity  of  the  disc  and  of  the  white  figure,  the  choroid  is  ob- 
served to  be  somewhat  thinned ;  on  the  left,  the  pigment  in  the  epithe- 
lial layer  is  diminished,  and  hence  the  choroidal  vessels  are  particularly 
marked.  The  intra- vascular  spaces  are  here  also  peculiarly  conspicuous 
and  striking,  which  is  due  to  the  increase  in  the  pigment  of  the  stroma. 
Whereas,  on  the  right  side  of  the  figure,  the  pigmentation  of  the  epi- 
thelial layer  conceals  the  subjacent  tissue  and  the  vessels. 


Fig.  4. 

Choroiditis  Disseminata  Syphilitica,  ivith  Secondary  Atrophy  of  the  Retina 
and  Optie  Nerve  (p.  422). 

In  this  figure  we  notice  very  numerous,  irregular,  circumscribed 
spots  of  a  palish-pink  or  whitish  tint,  surrounded  by  a  dark  fringe  of 
pigment ;  others,  appearing  simply  as  small  black  patches.  In  some  of 
the  larger  spots,  a  choroidal  vessel  can  be  distinctly  seen  to  pass  over 
it.  The  optic  disc  is  atrophied,  and  of  a  bluish  tint.  It  is  completely 
devoid  of  blood-vessels,  excepting  the  two  little  twigs  which  can  just 
be  discerned  running  over  its  edge.  But  not  a  single  retinal  vessel  can 
be  seen  over  the  whole  fundus  ;  and  on  account  of  this  atrophy  of  the 
retina,  the  choroidal  vessels  appear  with  unusual  distinctness. 


Plate  U. 


i 


3  A 


722  EXPLANATION   OF   THE   PLATES. 


PLATE  III. 

Fig.  5. 

Betinitis  Pigmentosa  (p.  349). 

Numerous  large,  irregular,  black  figures  are  observed  scattered 
about  the  fundus,  being  arranged  at  some  points  along  the  retinal 
vessels,  which  are  extremely  attenuated,  and  here  and  there  quite  un- 
apparent.  At  other  situations,  the  black  patches  show  irregular  pro- 
longations, the  extremities  of  which  touch  those  of  other  spots.  Hence 
they  assume  a  certain  similarity  to  bone  corpuscles.  The  optic  nerve 
is  white  and  atropliied,  and  the  retinal  arteries  are  excessively  small 
and  attenuated. 


Fig.  6. 

Betinitis  Albmninurica  (p.  336). 

This  illustration  is  peculiarly  characteristic  of  the  ophthalmoscopic 
appearances  presented  by  the  retinitis  met  with  in  Bright's  disease.  At 
the  disc,  and  in  its  vicinity,  is  observed  a  delicate  grey  opacity,  which  is 
caused  by  a  serous  infiltration  and  proliferation  of  the  connective  tissue 
of  the  retina.  Beyond  this,  lies  the  white  glistening  mound,  which  is 
due  to  sclerosis  of  the  optic  nerve  fibres  and  fatty  degeneration  of  the 
connective  tissue  elements.  The  extreme  margin  of  this  white  mound 
is  broken  tip  into  small,  irregular  patches,  which  assume,  in  the  region 
of  the  yellow  spot  (to  the  left  of  the  disc),  a  peculiar  stellate  arrange- 
ment, looking  as  if  they  had  been  splashed  in  with  a  brush.  The 
retinal  arteries  are  much  diminished,  both  in  calibre  and  number. 
The  veins  are  dilated  and  tortuous,  and  the  vessel  running  upwards, 
is  interrupted  in  its  course  by  the  infiltration,  and,  at  the  point  of 
interruption,  are  noticed  well-marked  blood  extravasations.  These,  as 
well  as  most  of  the  other  heemorrhages,  show  by  their  irregular  outline 
and  striated,  feathery  appearance,  that  they  lie  in  the  optic  nerve  layer 
of  the  retina. 


Plate  ll. 


3  A  2 


724  EXPLANATION  OF  THE  PLATES. 


PLATE  IV, 

Fig.  7. 

Ecemorrhagic  Effusions  into  the  Retina,  Betinitis  Apoplectica  (p.  347). 

[At  p.  347  this  figure  has  been,  by  mistake,  described  as  being  on  Plate  VI.] 

In  Fig.  7,  numero-as  blood  effusions  of  varying  size  and  shape  are 
noticed  in  tlie  retina,  being  situated  in  different  layers  of  the  latter. 
But  even  between  tbe  larger  patches,  the  retina  is  not  free,  for  minute 
hemorrhagic  spots  are  strewn  about  in  all  directions.  The  retinal 
arteries  are  here  and  there  filled  with  blood  coagula,  but  at  other 
points  they  are  quite  bloodless,  and  changed  into  narrow  white 
bands.     In  a  few  branches,  the  circulation  is,  however,  unimpeded. 


Fig.  8. 

Embolism  of  the  Central  Artery  of  the  Retina  (p.  363). 

Here  we  notice,  in  the  region  of  the  yellow  spot,  a  well  marked 
greyish  white  opacity,  which  is  due  to  a  serous  infiltration  of  the 
retina.  In  its  centre,  is  a  conspicuous  cherry- coloured  spot  which 
is  not  caused  by  a  blood  effusion,  as  might  be  supposed  at  the  first 
glance,  but  is  due  to  the  fact,  that  the  retina  is  transparent  at  this 
point,  and  thus  permits  the  choroid  to  shine  through,  which  assumes  a 
redder  tinge  in  consequence  of  the  contrast  with  the  greyish-white 
opacity.  The  vessels  running  towards  the  yellow  spot,  are  particularly 
conspicuous  on  account  of  the  blood  coagula  which  they  contain,  and 
of  the  white  opacity.  The  outline  of  the  disc  is  slightly  undefined 
and  encircled  by  a  faint  opacity.  The  retinal  veins  show  a  distinct 
retardation  in  the  circulation,  and  contain  here  and  there  blood 
coagula.  The  arteries  are  greatly  diminished  in  size,  and  become  quite 
indistinct  at  certain  points  of  tlieii'  course. 


Plate  IV. 


726  EXPLANATION  OF  THE  PLATES. 


PLATE  V. 

Fig.  9. 

Cysticercus  in  the  Vitreous  Humour  (p.  325). 

This  figure  illustrates  the  appearance  presented  by  a  cysticercus 
in  the  vitreous  humour.  The  entozoon  shows  itself  in  the  form  of  a 
well-defined,  bluish-grey  vesicle,  which  is  so  transparent,  that  in  the 
central  portion  the  red  tint  from  the  choroid  can  be  distinctly  seen  to 
shine  through.  The  neck  is  more  opaque  in  tint  than  the  rest  of  the 
entozoon,  and  is  studded  with  small  white  dots  (chalky  particles). 
At  the  head,  two  suckers  can  be  recognised,  the  other  two  being 
placed  posteriorly.  The  buccal  extremity  is  directed  upwards.  The 
small,  circular,  grey  spots  which  partly  encircle  the  vesicle,  are  caused, 
according  to  Liebreich,  by  a  peculiar  opacity  of  the  vitreous  humour 
due  to  the  suction  of  the  entozoon,  and  are  quite  characteristic  of  the 
presence  of  a  cysticercus. 


Fig.  10. 

Detachment  of  the  Retina  (p.  353). 

Fig.  10  represents  a  case  of  old  standing  and  extensive  detachment 
of  the  retina.  The  lower  half  of  the  retina  (which  shows  a  tolerably 
sharply-defined  edge  towards  the  left)  bulges  forwards  into  the  vitreous 
humour,  and  is  thrown  into  well-marked  folds,  and  on  this  account, 
as  well  as  of  the  colour  of  the  subjacent  fluid,  it  shows  a  peculiar 
greenish-grey  tint.  The  retinal  vessels  are  undulating  and  tortuous, 
riding  on  the  folds  of  the  retina,  and  they  assume  a  darker  tint  in 
consequence  of  the  grey  background. 


Plate  V. 


728  EXPLANATION   OF   THE   PLATES. 

PLATE  VI. 

Figs.  11  and  12. 

AtropJnj  of  the  Optic  Nervr  (p.  385). 

Fig.  11  shows  the  appearances  presented  by  atro|)hy  of  the  optic 
nerve,  in  a  patient  aflfected  with  loco-motor  ataxy.  The  disc  is  slightly 
excavated,  and  of  the  peculiar  bluish  mottled  tint,  so  frequently  ob- 
served in  the  atrophy  dependent  upon  spinal  disease.  The  arteries  are 
small  and  attenuated.  Fig.  12  represents  a  case  of  white  atrophy 
after  meningitis.  The  disc  is  very  white,  and  faintly  cupped.  The 
arteries  are  much  diminished  in  calibre,  and  some  of  the  veins  (as  some 
of  those  in  Pig.  11)  show  a  well-marked,  white  streak  along  their 
margin,  which  is  due  to  sclerosis  of  the  tunica  adventitia. 

Figs.  13  and  14. 

O'ptic  Neuritis  (p.  375). 

In  Fig.  13  is  represented  the  swollen  and  enlarged  papilla  con- 
sequent upon  optic  neuritis,  the  opacity  of  the  disc  being  dense  and 
m.arkedly  striated.  The  retinal  veins  are  enlarged  and  tortuous,  the 
arteries  diminished  in  size,  and,  here  and  there,  hidden  by  the  exuda- 
tion. Fig.  14  shows  the  condition  of  the  same  optic  nerve  two  years 
later,  when  consecutive  atrophy  had  supervened.  The  uniformly 
opaque  tint  of  the  disc,  as  well  as  its  somewhat  undefined  margin,  help 
to  distinguish  it  at  a  glance  from  the  progressive  form  of  atrophy 
(Fig.  12).  Moreover,  although  the  veins  are  less  dilated  than  in 
Fig.  13,  they  yet  retain  a  certain  degree  of  tortuosity. 


Figs.  15  and  16. 

Glazicomatovs  excavation  of  the  Optic  Nerve  (p.  390). 

In  these  two  figures,  are  observed  different  degrees  of  glauco- 
matous excavation.  Both  present  all  the  characteristic  features  of  this 
disease,  but  in  Fig.  15  they  are  less  marked  than  in  Fig.  16,  in  which 
the  cup  is  much  deeper  and  more  abrupt.  In  each  case,  the  disc  is 
surrounded  by  a  pale  light  girdle,  its  colour  is  much  darker  at  the 
periphery  than  in  the  centre,  and  the  retinal  vessels  are  more  or 
less  considerably  bent  or  interrupted  at  the  edge  of  the  papilla. 


Plate  M. 


INDEX. 


Abscess  of  cornea,  99. 
lachrymal  sac,  613. 

orbit,  627. 

frontal  sinus,  661. 

Ahsorpllon,  cure  of  cataract  by,  265. 
Accomniodalioii,  nature  of,  498. 

action  of  atropine  upon,  162. 

action  of  Calabar  beau  upon,  540. 

mechanism  of,  500. 

negative,  502. 

paralysis  of,  539. 

range  of,  503. 

binocular  range  of,  505. 

negative  range  of,  505. 

Acne  ciliaris,  677. 

Acuteness  of  vision,  modes  of  estimating, 

4. 
Aegilops,  670. 

Agneio,  Dr.,  on  capsular  cataract,  276. 
Albuminuria,  a  cause  of  retinitis,  336. 

a  cause  of  amblyopia,  341,  412. 

AUbutt,  Dr.,  on  optic  neuritis,  376. 

on  the  state  of  the  optic  nei've  in 

the  insane,  404. 
Althaus,  Dr.,  on  electrolysis,  655,  687. 

on  locomotor  ataxy,  407. 

Amaurosis,  396. 

simulation  of,  420. 

Ametropia,  500. 
Ambli/opic  affections,  396. 
Amblt/ojna,  412. 

ex  anopsia,  413,  578. 

a'nsemic,  409. 

from  blood  poisoning,  410. 

congestive,  409. 

potatorum,  410. 

saturniua,  412.——  "[Ji^j,^  , 

from  tobacco,  411. 

ura?mic,  412. 

from  uon-use,  413,  578. 

Anchylohlepharon,  80. 

Aiichylops,  670. 

Amlerson,  Dr.  McCall,  on  eczema  of  lid, 

676. 
Aneurism  of  the  orbit,  651. 

by  anastomosis,  in  orbit,  654. 

of  eyelids,  686. 

of  central  artery  of  retina,  655. 

Anterior  chamber,  changes  in  the  con- 
tents of,  etc..  182. 


Anthrax,  of  the  eyelids,  672. 

Aphakia,  538. 

Aqueous  humour,   cure   of  cataract   by 

repeated  evacuation  of,  273. 
Aquo-capsulitis,  148. 
Arciis  senilis,  128. 
Arlt,  Prof,  on  cause  of  pterygium,  74. 

on  operation  for  entropium,  696. 

Artificial  eye,  mode  of  insertion,  QGQ. 

leech,  13. 

Asthenopia,  due  to  hypermetropia,  522. 

muscular,  600. 

retinal,  522. 

Astigmatism,  525. 

acquired,  533. 

compound,  532. 

congenital,  533. 

diagnosis  of,  526,  529. 

irregidar,  528,  537. 

mixed,  532,  536. 

regidar,  528,  533. 

simple,  532,  534. 

ophthalmoscopic  diagnosis  of,  532. 

treatment  of,  bv  cylindrical  lenses, 

534. 
Ataxy,  locomotor,  a  cause  of  amam-osis, 

403. 
Atresia  of  the  lachrymal  puncta,  612. 
Atrophy  of  the  optic  nerve,  385. 

of  the  retina,  374. 

Atropine,  action  of,  on  the  accommoda- 
tion, 162. 
on  the  iris,  162. 

anomalous  effects  of,  94 — note. 

idiosyncrasy  against,  93 — note. 

in  ii'itis,  154. 

necessity   of  its    being  pure,  93 — 

note. 

poisoning  by,  157. 

Aut-ophthahnoscope   of   Giraud   Teulon, 

207. 
Axes,  secondary  of  lenses,  490. 
Axis,  o])lic,  49  i. 

of  turning,  549. 


B. 


Bader,  Mr.,  on  inoculation,  62. 

on  syndectomy,  01 — note. 

Bandages,  different  forms  of,  11. 

compress  bandage  in  corneitis,  105, 


730 


INDEX. 


Sandages,  Vou  Grraefe's,  12. 

■ Liebreicli's,  11. 

JSasedowii,  Morbus,  634. 

Seeker,  Dr.,  on  accommodation  of  the 
eye,  501. 

£ell,  Dr.  Joseph,  on  aneurism  of  orbit, 
656. 

Belladonna  ointment,  21. 

Benedikt,  Dr.,  on  electricity,  568. 

Bergmann,  Dr.,  on  retinitis  albuminurica, 
339. 

Bergeron,  Dr.,  on  treatment  of  epithelial 
cancer  of  lids,  686. 

Berlin,  Dr.,  on  diphtheritic  conjunc- 
tivitis, 44. 

on   extirpation   of  lachrymal    sac, 

625. 
Binocular  vision,  mode  of  examination 

of,  576. 

in  sti'abismus,  575,  577. 

Black  eye,  715. 
Blenorrhaea,  22i. 

of  lachrymal  sac,  617. 

Blepharitis  marginalis,  674. 
Blepharo-adenitis,  675. 
Blepharoplasty ,  710. 
Blepharospasm,  690. 

Blood   effused    into    anterior   chamber, 

183. 
choroid,  453. 

conjunctiva,  87. 

■  eyelids,  714. 

orbit,  659. 

retina,  332,  347. 

vitreous  humour,  316. 

Bohm,  Dr.,  on  Nystagmus,  570 
Bonnet,  capsule  of,  587. 

BorelU's,  Dr.,  operation  for  staphvloma, 

140. 
Boioman,  Mr.,  on  aneurism  of  the  orbit, 

657. 

on  abscess  of  frontal  sinus,  662. 

on  astigmatism,  533. 

on  conical  cornea,  131. 

on  treatment  of  capsular  opacities, 

by  two-needle  operation,  275. 

on  iridectomy,  176. 

on  irido-choroiditis,  193. 

on  treatment  of  obstructed  ducts, 

610. 

on  treatment  of  detached   retina, 

359. 

on  scoop  extraction  of  cataract,  256. 

suction  syringe  for  cataract,  272. 

on  strabismus,  573. 

sympatlictic  ophthalmia,  200. 

on  estimating  the  degree  of  tension 

of  the  eye,  2. 
Brachymetropia,  499. 
Broadbent,  Dr.,  on  treatment  of  cancer 

by  injection  of  acetic  acid,  668. 
Busch,  Dr.,  on  tubercles  in  the  choroid, 

440. 
Buphthahnos,  133. 


Buys,  Dr.,  on  use  of  acetate  of  lead  in 
granular  ophthalmia,  58. 


Calabar  bean,  action  of  on  iris,  162. 

ciliary  muscle,  540. 

Calculus  lachrymal,  608. 

Meibomian,  682. 

Calomel,  insufflation  of,  67. 
CanaUculi,  division  of,  612. 

obstructions  in,  612. 

Cancer  of  choroid,  448. 

of  conjunctiva,  86. 

epithelial,  of  eyelids,  684. 

of  orbit,  647,  648. 

Canthoplastg ,  699.  • 

Canton,  Mr.,  on  arcus  senilis,  128. 
Capsule  of  Bonnet,  587. 

Tenon,  587. 

Capsular  cataract,  227- 

anterior,  228. 

posterior,  224. 

Carbuncle  of  the  eyelids,  672. 

Cardinal    points   in   diagrammatic  eve, 

495. 
Caries  of  the  orbit,  632. 
Carter,  Mr.,  on  injm-ies  of  orbit,  663. 

on  compound  object  lens,  302. 

Cartilagineous  tumours  of  orbit,  6i3. 
Cataract,  aetiology  of,  215. 

diagnosis  of,  217. 

symptoms  of,  217. 

anterior  capsidar,  228. 

black,  223. 

capsular,  227. 

congenital,  219,  221. 

cortical,  22  2. 

diabetic,  215. 

lamellar  or  zonidar,  219. 

Morgagnian,  226. 

nuclear  or  hard  senile,  223. 

posterior  capsiilar  (polar),  224. 

pyramidal,  228. 

siliculose  or  chalky,  222. 

traumatic,  226. 

treatment  of,  by  division,  265. 

by  flap  extraction,  233. 

with  iridectomy,  249. 

by  Von  Graefe's  extraction, 

258. 

by  linear  extraction,  252. 

by  repeated  paracentesis  cor- 

nese,  273. 

by   rechnation   or  couching, 

265. 

by  scoop  extraction,  255. 

by  suction,  271. 

by   I'emoval   of    lens    in    its 

capsule,  250. 
of  lamellar,  269. 

of  traumatic,  270. 

secondary,  operations  for,  274. 


IXDEX. 


731 


Catarrhal  ophthalmia,  16. 

CaVs-eye,  amaurotic,  368. 

Catoptric  test,  218. 

Catisiics,  on  the  use  of,  in  purulent  opli- 

thalmia,  32. 
Caustic  mitigated,  on  use  of,  33. 
Cellulitis  of  the  orbit,  627. 
Charpie,  12 — note. 
Chalazion,  681. 
Chemosis,  18. 

Chlorine  water,  use  of,  53,  60,  69. 
Gholesterine  in  vitreous  hiunour,  321. 
Clover's,  Mr.,  chlorofonn-apparatus,  250. 
Choroid,  diseases  of,  422. 

cavernous  sarcoma  of,  450. 

carcinoma  of,  4rl8. 

colloid  disease  of,  439. 

coloboma  of,  450. 

detachment  of,  454. 

formation  of  bone  in,  450. 

haemorrhage  from,  453. 

hjpercemia,  of,  422. 

mjoma  of,  449. 

rupture  of,  451. 

— —  sarcoina  of,  443. 

tubercles  of,  440. 

tumours  of,  443. 

Choroiditis  areolar,  424. 

disseminated  or  exudative,  422 

syphiUtic,  423. 

suppurative,  434. 

Chromhydrosis,  679. 

Ciliary  body,  inflammation  of,  206. 

muscle,  affections  of,  539. 

atony  of,  541. 

paralysis  of,  539. 

spasm  of,  541. 

nem-algia,  19. 

region,  injm-ies  of,  208. 

Circles  of  diffusion,  495. 

Coccius,  Prof.,  compound  object  lens  of, 
302. 

ophthalmoscope  of,  291. 

ou  glaucoma,  475. 

Cohii,  Dr.,  on  mica  spectacles,  546. 

on  myopia,  508. 

Cohnheim,  Dr.,  on  tubercles  of  choroid, 

440. 
Coloboma  of  eyelid,  717. 

of  iris,  170. 

of  choroid,  450. 

Colloid  disease  of  choroid,  439. 
CoZo?<r-blindness,  419. 

Coynpression,  digital,  iu  orbital  aneurism, 

658. 
Conical  cornea,  128. 

treatment  of,  bv  iridectomy, 

131. 

■ iridodesis,  131. 

Von  Graefe's,  131. 

Conjunctiva,  diseases  of  the,  15. 
■  cysts  of,  85. 

cysticercus  in,  85. 

• emphysema  of,  88. 


Conjunctiva,  epithelial  cancer  of,  86. 

heemorrhage  into,  87. 

hypertcmia  of,  15. 

injuries  of,  81. 

lithiasis  of,  87. 

medullary  cancer  of,  86. 

melanotic  cancer  of,  86. 

•  nsevi  of,  87. 

oedema  of,  88. 

polypus  of,  83. 

syphilitic  ulcers  of,  87. 

tumours  of,  83. 

Conjunctival  discharge,  contagiousness  of, 

28. 
Conjunctivitis,  catarrhal,  16. 

exanthema  tons,  70. 

diphtheritic,  40. 

gonorrhoeal,  36. 

gi'anidar,  45. 

phlyctenular,  64. 

purulent,  22. 

Contusions  of  eyelids,  715. 
Convergent  strabismus,  579. 
Coredialysis,  181. 
Corelysis,  180. 

Cor  ectopia,  171. 
Cornea,  diseases  of,  89. 

abscess  of,  99. 

conical,  128. 

■ — —  treatment  of,  by  iridectomy, 

131. 

by  iridodesis,  131. 

Von  Graefe's,  131. 

fistula  of,  116. 

hernia  of,  110. 

herpes  of,  91. 

injuries  of,  140. 

nem-o-paralytic  affection  of,  102. 

opacities  of,  122. 

paracentesis  of,  100,  113. 

perforation  of,  26,  111. 

staphyloma  of,  134,  135. 

suppuration  of,   after  flap  extrac- 

tion, 245. 

tumoiu's  of,  143. 

idcers  of,  108. 

crescentic  ulcer  of,  109. 

perforating  ulcer  of,  109. 

transparent  ulcer  of,  110. 

vesicles  on  the,  95. 

Corneitis,  difluse,  117. 

vascular  diffuse,  117, 

'  non-vascular  diffuse,  121. 

fascicidar,  95. 

phlyctenular,  91. 

suppurative,  97. 

inflammatory  suppurative,  98. 

non-inflammatory  su])purative,101. 

Couper,  Mr.,  on  sympathetic  ophthalmia, 

199. 
Couching,  265. 
Critchetl,  Mr.,  on  iridodesis,  178. 

operation  of,  on  canaliculus,  613. 

of  re-adjustment,  599. 


732 


INDEX. 


Critchett,  Mr.,  operation  of,  for  strabis- 
mus, 593. 
for  staphyloma,  137. 

on  use  of  seton  in  iilcers  of  the 

cornea,  ll-i. 

on  scoop  extraction,  256. 

Cyclitis,  206. 

Cylindrical  lenses,  534. 

■ use  of,  in  astigmatism,  534. 

Cylindroma  of  eyelid,  684. 
Cyst,  tarsal,  681. 

in  iris,  167. 

Cystlcerens  in  anterior  chamber,  184. 

of  tlie  orbit,  616. 

in  vitreous  humour,  323. 

Cysfoid  cicatrix  in  glaucoma,  487. 


D. 


Dacryo-adenitis,  605. 

Dacryocystitis,  613. 

Dacryoliths,  608. 

Dacryops,  606. 

Daltonism,  419. 

Deformity  of  orbit  from  pressure,  660. 

De  Morgan,  Mr.  Campbell,  on  medullary 

cancer  of  orbit,  650. 
Depression  of  cataract,  265. 
Descemetitis,  148. 

Destruction  of  lachrymal  sac,  624. 
Detachment  of  the  retina,  353. 

of  the  choroid,  454. 

Deviation,  primary,  of  risual  lines,  554. 

secondary,  of  visual  lines,  554. 

in  paralytic  affections  of  ocvi- 

lar  muscles,  555. 

in   strabismus    concomitans, 

572. 

Dieffenhaclrs   operation    for    ectropimn, 

709. 
Digital  pressure  in  orbital  aneurism,  658. 
Diplitheritie  conjunctivitis,  40. 
Diplopia,  homonymous,  9. 

crossed,  9. 

monocular,  538. 

operations  for,  597- 

Dislocation  of  the  eye,  664. 

of  the  lens,  277. 

Distichiasis,  692. 
Tiiveryent  strabismus,  582. 
Division  of  cataract,  265. 

Dixon,  Mr.,  on  peculiar  deposit  in  cornea, 
124. 

on  dislocation  of  lens,  280. 

Donders,  Prof.,  on  ametropia,  500. 
• on  astigmatism,  525. 

on  brachymetropia,  499. 

on  colloid  disease  of  choroid,  439. 

on  emmctropia,  498. 

on  entoptics,  319. 

on  glaucoma,  470. 

on  hypermcti'opia,  499. 

on  retinitis  pigmentosa,  351. 


Donders,  Prof.,  on  sclerotico-choroiditis 

posterior,  432. 
— —  on  stenopaic  spectacles,  127. 

sympathetic  ophthalmia,  195. 

on  vertical  meridian,  548. 

on  visual  line,  496. 

Duct,  lachrymal,  obstruction  of,  618. 

—  Bowman's   treatment    of, 

619. 
—  Critchett's   treatment  of, 

619. 
Stillings'     treatment     of, 

622. 
—  Warlomont's  treatmentof, 

622. 
Weber's  treatment  of,  620. 

nasal,  stricture  of,  618. 


E. 


Ecchymosis  of  conjunctiva,  87. 

of  eyelids,  714. 

of  retina,  332,  347. 

'Ecliinococcus  in  orbit,  646. 
Ectopia  lentis,  277. 
Ectropium,  703. 

from  inflammatory  hypertrophy  of 

coujinictiva,  704. 

from  cicatrices,  vrounds,  &c.,  704. 

from  caries,  705. 

Adams'  operation  for,  707. 

Dieffenbach's  operation  for,  709. 

Graefe's  operation  for,  709. 

Hasner's  operation  for,  714. 

Wharton  Jones'  operation  for,  708. 

Knapp's  operation  for,  713. 

treatment  by  blepharoplasty  (trans- 
plantation), 710. 

treatment  of,  by  tarsoraphia,  706. 

Eczema  of  the  lids,  674. 

Effusion,  of  blood,  into  anterior  chamber, 

183. 
into  choroid,  453. 

into  conjunctiva,  87. 

into  eyelids,  711. 

into  retina,  332. 

into  vitreous  humour,  316. 

Egyptian  ophthalmia,  22. 

Electricity,  in  paralysis  of  ocular  muscles, 

568. 
Electrolysis,  655,  686,  687. 
Embolism,  of  choroidal  vessels,  438. 

of  retinal  artery,  363. 

Emmetropia,  498. 
Emphysema  of  eyelids,  668. 
Enchondroma  of  orbit,  645. 
Encysted  tumours  of  orbit,  645. 
Entoptics,  319. 

Entozoa,  vide  Cysticercus  and  Ecliino- 
coccus. 
Enfropiiim,  697. 

acute  or  spasmodic,  698. 

chronic,  698. 


INDEX. 


733 


Entropiiini,  senile.  fiOS. 

Arlt's  operation  for,  G96. 

Autlior's  operation  for,  703. 

Graefe's,  700. 

Pagenstecher's,  701. 

Snellen's,  702. 

Streatfeild's,  702. 

EtiKclratioii  of  eyeball,  664. 

Ephidrosis,  678. 

Epicanthus,  717- 

EpUepsif  of  the  retina,  361. 

Epiphora,  600. 

Episcleritis,  65,  200. 

Epithelial  cancer  of  eyelids,  681;. 

Erectile  tumom-s  of  eyelids,  686. 

of  orbit,  651. 

Eruptions,  syphilitie,  of  eyelids,  672. 
Eri/sipelas  of  eyelids,  671. 
Erqtlicma  of  eyelids,  669. 
Evacuation  of  aqueous  humour,  35,  113. 
E version  of  the  upper  lid,  1. 

of  the  eyelids,  703. 

Exanthematous  ophthalmiae,  70. 
Excavation  of  optic  nerve,  388. 
atrophic,  389. 

—  glaucomatous,  390. 

phy^iolo<;ieal,  309. 

Excision  of  eyeball,  iMi. 
Exojihthalmic  goitre,  634. 
Exostosis  of  orbit,  631,  613. 
Extirpation  of  eyeball,  664. 

of  lacliryinal  gland,  608. 

of  lachrymal  sac,  625. 

Extraction,  of  cataract,  in  capsule,  250. 

by  iiap  operation,  233. 

by  Yon   Graefe's   operation, 

258. 

by  linear  incision,  252. 

by  scoop  operation,  255. 

by  suction,  271. 

Eye,  diagrammatic  eye  of  Listing,  495. 

douche,  14. 

general  inflanunation  of,  434. 

rupture  of,  211. 

Eyehall,  dislocation  of,  664. 

excision  of,  664. 

Eyelashes,  inrersion  of,  692. 

transplantation  of,  696. 

Eyelids,  diseases  of,  668. 

abscess  of,  669. 

anthrax  of,  672. 

contusions  of,  714. 

ecchymosis  of,  714. 

encysted  tumours  of,  681. 

epithelial  cancer  of,  684. 

erysipelas  of,  671. 

erythema  of,  669. 

eversion  of,  703. 

inflammation  of  edges  of,  674. 

inversion  of,  697- 

nsevus  of,  686. 

oedema  of,  668. 

tumours  of,  681. 

ulcers,  syphilitic,  of,  686. 


Eyelids,  warts  of,  681. 
wounds  of,  715. 


Far  point,  503. 

Farsightedness,  515. 

Fatty  degeneration  of  retina,  339. 

ii^  retinitis  albuminurica,  339. 

tumours  of  conjunctiva,  81. 

of  eyelids,  681. 

Fibroma  of  eyelid,  684. 

of  orbit,  639. 

Field  of  vision  in  amblyopic  alTcctions, 
397,  105. 

eontra(!tion    of,   in  detached 

retina,  356. 

in  retinitis  pigmentosa, 

352. 

eiToncous  projection  of,  555. 

in  hemiopia,  398. 

equilateral   or    homonymous 

contraction  of,  398. 

examination  of,  5. 

Author's  method,  7. 

Mr.  Teale's,  8. 

Dr.  Wecker's,  8. 

Fistula  of  cornea,  116. 

of  lachrymal  sac,  625. 

Flap  exti-action  of  cataract,  233. 
Focal  interval,  527. 

line,  anterior,  527. 

posterior,  527. 

Focus  of  lenses,  489,  493. 
Foci,  conjugate  of  lenses,  490. 
Fomentations,  warm,  in  suppm-ative  cor- 

neitis,  104. 

Foreign  bodies  in  the  conjimctiva,  81. 

cornea,  140. 

iris,  167. 

lens,  227. 

vitreous,  321. 

Formation  of  bone  in  choroid,  450. 

Forster,  Dr.,  on  areolar  choroiditis,  424. 

Fractures  of  wails  of  orbit,  664. 

Frank,  Dr  ,  on  granular  ophthalmia,  46. 

on  rupture  of  the  choroid,  453. 

Eraser,  Dr.,  on  Calabar  bean,  510. 

Freeman,  Dr.,  on  digital  compression  of 
orbital  aneurism.  658. 

Frontal  sinus,  diseases  of,  660. 

abscess  of,  661. 

Fundus  oevdi,  ophthalmoscoj^ic  appear- 
ances of  healliiy,  305. 

Fungus,  hsomatodcs  of  eyeball,  370. 

Furnari,  Dr.,  on  syndeetomy,  61. 


G. 


Galvano-cnus1ica,\)^a,VAU\s  for  de.  truction 

of  lachrymal  sac,  624. 
Gerontoxon  (arcus  senilis),  128. 


734 


INDEX. 


Gibson's  operation  for  cataract,  252. 
Gioppi,  Dr.,  on    digital    compression   of 

orbital  aneurism,  658. 
Giraud- Teuton's,     Dr.,     aut-oplitlialmo- 

scojie,  297. 

binocular  ophthalmoscope,  294. 

Gland,  lachi-ymal,  diseases  of,  606. 

extirpation  of,  608. 

Glaucoma,  456. 

acute  inflammatory,  459,  463. 

chronic  inflammatory,  467. 

fulminans,  467. 

hsemorrhagic  form  of,  466. 

• iridectomy  in,  485. 

nature  and  causes  of,  474. 

premonitory  stage  of,  459. 

■  prognosis  of,  479. 

simplex,  470. 

subacute,  466. 

Glioma  of  retina,  367. 
Glio-sarcoma  of  retina,  367. 
Goitre  exophthalmic,  634. 
Gonorrheal  ophthalmia,  37. 

iritis,  152. 

Graefe,  Yon,  Prof.,  on  amblyopic   affec- 
tions, 396. 

on  bandages  for  the  eye,  12. 

on  treatment  of  cataract  by  linear 

extraction,  252. 
— —  operation  of,  for  cataract,  258. 

on  use  of  caustic  in  ophthalmia,  33. 

on  conical  cornea,  131. 

on  cysticercus  in  vitreous,  323, 324. 

on  ectropium,  709. 

on  embolism  of  central  artery  of 

retina,  363. 

on  entropium,  700. 

-  ■  on  exophthalmic  goitre,  634. 

on  fomentations  (warm),  58,  104. 

on  glaucoma,  457. 

on  glioma  retinse,  368,  370. 

on  irido-choi'oiditis,  192-3. 

on  muscular  asthenopia,  601. 

• on  muscles  of  the  eye,  548. 

on  tumours  of  optic  nerve,  393. 

on  optic  neuritis,  376. 

on  ptosis,  389. 

on  retro-ocular  optic  neuritis,  384. 

'  on  detachment  of  retina,  359. 

on  hypersesthesia  of  retina,  366. 

on  central  recurrent  retinitis,  346. 

— —  on  trichiasis,  697. 

on  sarcoma  of  choroid,  443. 

on  sclerotico-choroiditis  posterior, 

431. 

on  operation  for  staphyloma,  139. 

on  strabismus,  577. 

on  operation  for  strabismus,  587. 

on    operation    for    re-adjustment, 

598. 

on  sympathetic  ophthalmia,  196. 

on  sympathetic   choroido-retinitis, 

197. 
on  tubercles  of  the  choroid,  440. 


Graefe,  Alfred,  Dr.,  on  ischsemia  retinse, 
362. 

on  the  muscles  of  the  eye,  549. 

Granular  ophthalmia  (acute),  50. 
Granulations,  chronic,  53. 

vesicular,  46. 

Graves's  disease,  634. 

Greens,  Dr.,  test-objects  for  astigmatism, 

529. 
Guthrie,  Mr.,  on  aneurism  of  orbit,  655. 

^.^..^  dc^/p ...  s^- z2;>.  z ^ 

H. 

Saffmans,  Dr.,  on  glaucoma,  470. 
Hasner,  Dr.,  on  pterygium,  74. 

on  ectropium,  714. 

Scemorrhage  into  anterior  chamber,  183. 

from  choroid,  453. 

into  conjunctiva,  87. 

into  orbit,  659. 

into  retina,  332,  347. 

into  vitreous  humom*,  316. 

cerebral,  a  cause  of  amaurosis,  402. 

Helmlioltz,  Prof.,  on  accommodation  of 

eye,  500. 

ophthalmoscope  of,  287. 

on  the  visual  line,  494. 

Semeralopia,  416. 

in  retinitis  pigmentosa,  352. 

Hemiopia,  398. 

equilateral  or  homonymous,  398. 

tempoi-al,  398. 

Herpes  of  the  conjunctiva,  64. 

of  the  cornea,  91. 

Herzenstein,   Dr.,  on  treatment   of  tri- 
chiasis, 694. 

on  stricture  of  lacln-ymal  passages, 

622. 
Seurteloup,  Baron,  artificial  leech  of,  13. 
Sippus,  164. 
Hirschherg,  Dr.,  on  glioma  retinse,  368, 

370.- 
Hordeolum,  679. 
Horner,  Dr.,  on  glaucoma,  476. 
HulTce,  Mr.  J.  W.,  on  aneurism  of  orbit, 

657. 
— —  on  colloid  disease  of  choroid,  446. 

on  cysts  in  the  iris,  168. 

on  epithelial  cancer  of  orbit,  653. 

on  diseases  of  frontal  sinus,  660. 

on  glioma  retinse,  372. 

on  optic  ueimtis,  382. 

on  sarcoma  of  choroid,  446. 

on  sarcoma  of  orbit,  643. 

Hutchinson,    Mr.    Jonathan,    on   diflfuse 

corneitis,  120. 

on  glauc  oma,  476. 

on  optic  neuritis,  377. 

on  pyraniida  Jcataract,  228. 

on  tobacco  amaurosis,  387. 

Hi/alilis,  315, 

Hi/nloid  artery,  i^ersistent,  326. 
Hydatids  of  orbit,  646. 


INDEX. 


78o 


Hydrophthalmia,  132. 

HypcBmia,  183. 

Sypercemia  of  coujimctiva,  15. 

of  choroid,  422. 

of  iris,  144. 

of  retina,  327. 

Hypermelropia,  499,  517. 

absolute,  521. 

acquired,  520. 

faeidtatirc,  521. 

latent,  520. 

umnifest,  520. 

ophthalmoscopic  diagnosis  of,  518. 

original,  520. 

relative,  521. 

a  frequent  cause  of  asthenopia,  522. 

a   freqiient    cause    of    convergent 

squint,  523. 
Hypopyon,  dill'erent  origins  of,  99. 


Image,  actual,  of  fundus  oculi,  288,  299. 

virtual,  of  fundus  oculi,  289,  302. 

Infinite  distance,  meaning  of  tenn,  489. 
Infiammafion  of  cellular  tissue   of  orbit, 

627. 

of  choroid,  423. 

conjunctiva,  16. 

cornea,  16. 

edge  of  the  eyelids,  669. 

of  eye  generally,  434. 

of  b'is,  144. 

of  iris  and  choroid,  185. 

of  lachrymal  gland,  605. 

of  lachrymal  sac,  613. 

of  retina,  329. 

of  vitreous  humour,  313. 

Injection  of  lachrymal  passages,  616. 

sub-conjunctival,  of  salt  and  water 

in  corneal  opacities,  126. 
Injuries  of  the  ciliary  region,  208. 

of  the  conjunctiva,  81. 

of  the  cornea,  140. 

of  the  iris,  165. 

of  the  lens,  226. 

of  the  Uds,  714. 

of  the  orbit,  662. 

of  the  sclerotic,  213. 

Inoculation,  as  treatment  for  pannus,  62. 
Infiiifficiency  of  internal  recti  muscles,  600. 
Interval,  focal,  527. 

Intraocular  tension,  mode  of  estimating 

degree  of,  2. 
Inversion  of  lid,  697. 
Iridectomy,  mode  of  perfonning,  172. 

in  lamellar  cataract,  269. 

in  conical  cornea,  130. 

in  corneal  opacities,  127. 

in  corneitis,  107. 

in  glaucoma,  479,  485. 

in  irido-choroiditis,  190. 

in  iritis,  160. 


Irideclomi/,  indications  for  perfoi-manco 

of,  177. 
Irideremia,  170. 
Irido-choroiditis,  185. 
Irido-cyclitis,  146,  206. 
Iridodesis,  mode  of  performing,  178. 

in  lamellar  cataract,  269. 

•— —  in  conical  cornea,  131. 

•  in  corneal  opacities,  127. 

Iridodialysis,  181. 
Iridodonesis,  165. 

Iris,  congenital,  absence  of,  170. 

cancer  of,  169. 

coloboma  of,  170. 

cysts  of,  167. 

hyperaemia  of,  144. 

inflammation  of,  144. 

injuries  of,  165. 

prolapse  of.  111. 

tremulous,  165. 

tumours,  etc.,  of,  167. 

wounds  of,  165. 

Iritis,  144. 

— —  chronic,  152. 
gonorrhceal,  152. 

idiopathic,  simple,  148. 

parenchymatous,  149. 

serous,  148. 

suppurative,  149. 

sympathetic,  152. 

traumatic,  151. 

Iscliaimia  of  the  retina,  362. 
Iwanoff  on  glioma  of  the  retina,  371- 

on  retinitis,  333. 

on  perivascidar  retinitis,  334. 


Jackson,  Dr.  Hughlings,  on  epilepsy  of 
retina,  361. 

on  optic  nemntis,  378,  380. 

Jacobson,  Prof.,  on  cataract,  249. 

on  tumom-  of  optic  nerve,  393. 

Jaeger,  Prof,  v.,  on  staphyloma  posti- 

cum,  432. 

test  types  of,  4. 

Jago,  Dr.,  on  entoptics,  319. 

Jones,   Mr.    Wliarton,    on   astigmatism, 
525. 

on  operation  for  ectropium,  708. 

Javal,  Dr.,  optometer  of,  530. 

on  simulation  of  amam-osis,  421. 

on  treatment,  of  strabismus,  585. 


K. 


Keratitis,  see  corneitis. 

Keratocele,  110. 

Kerntoglohus,  132. 

Keratonyxis,    see    division    of    cataract, 

265. 
Knapp,  Dr.,  on  astigmatism,  532. 


736 


INDEX. 


Knapp,  Dr.,  on  ectropium,  713. 

on  embolism  of  clioroidal  vessels 

438. 
■  on  exostosis  of  orbit,  645. 

■ ou  metamorphopsia,  356. 

ou  glioma  of  the  retina,  372. 


L. 

Lachrymal  apparatus,  diseases  of,  605. 

calculns,  626. 

canals,  obstructions  of,  612. 

gland,  diseases  of,  605. 

cysts  of,  606. 

extirpation  of,  608. 

fistula  of,  607. 

hyperti'opliy  of,  606. 

indammation  of,  605. 

puncta,  e version  of,  610. 

malposition  of,  610. 

—  obliteration  of,  612. 

sac,  abscess  of,  613. 

blenorrhcea  of,  617. 

extirpation  of,  625. 

fistula  of,  625. 

liEcmorrhage  into,  626. 

^—  inflammation  of,  613. 

•  obliteration  of,  624. 

polypus  of,  626. 

LagophthaJmos,  689. 
Laminaria  bougies,  621. 

Lapis  divinus,  16 — note. 
Laurence,  Mr.   Zacliariali,  ou  aneurism 
of  orbit,  658. 

on  extirpation  of  laclu'ymal  gland, 

608. 

binocular  ophthalmoscope  of,  296. 

pupillometer  of,  161. 

on  retinitis  pigmentosa,  353. 

on  simulation  of  amam-osis,  421. 

strabismometer  of,  555. 

Laivson,  Mr.   Gleorge,  on  atropine,  94— 

note. 

on  inoculation,  63. 

on  recurrent  fibroid  orbital  tumovu-, 

613. 

on  scirrhns  of  oi'bit,  618. 

on  sympathetic  ophthalmia,  199. 

lon  syndectomy,  64. 

on  traumatic  cataract,  227. 

on  -svounds  of  the  iris,  166. 

Lead,  acetate  of,  in  granulations,  58. 

deposit  of,  on  cornea,  126. 

Learecl,  Dr.,  on  effect  of  Turkish  batli  on 

cerebral  circulation.  407 — note. 
Lens,  crystalli,ne,  all'ections  of,  215. 

absence  of  (aphakia),  538 

dislocation  of,  277. 

Lenses,  optical,  properties  of,  489. 

spherical,  489. 

convex,  489. 

concave,  492. 

— —  cylindrical,  531. 


Leucoma,  122. 

Lice  of  eyelashes,  678. 

Lids  (see  Eyelids). 

Lime,  effects  of,  thrown  into  eye,  83. 

Liebreich,  Dr.,  on  amaurosis,  397. 

bandage  of,  11. 

on  sypliilitic  choroiditis,  423. 

on  cysticercus  in  vitreous,  325. 

on  embolism  of  central  artery  of 

retina,  361. 
ophthalmoscope  of,  290,  293. 

on   pigmentation   of   optic   nerve, 

392. 

on  retinitis,  334. 

on  retinitis  leucsemica,  343. 

on  retinitis  pigmentosa,  353. 

on  operation  for  strabismus,  594. 

•  on  operation  for  re-adjustment,  599. 

Listing,  Dr.,  diagrammatic  eye  of,  495. 

on  entoptics,  319. 

Longsightedness,  515. 


M. 


Macula  lutea,  ophthabnoscopic  appear- 
ance of,  305. 
Mackenzie,  Dr.,  on  cclluhtis  of  orbit,  628. 

on  ectropium,  704. 

on  epithelial  cancer  of  lids,  685. 

on  exostosis  of  frontal  sinus,  660. 

on  exostosis  of  orbit,  643. 

on  niahgnant  pustule  of  the  lids, 

672 
Madarosis,  675, 
Malignant  pustule  of  Uds,  672. 
Manz,  Dr.,  on  tubercles  of  choroid,  440. 
Marston,  Dr.,  on  granular  ophthalmia, 

46— note,  49. 
Mauthner,  Dr.,    on  bifurcation  of  optic 

nerve  fibres,  395. 

on  discoloration  of  optic  nerve,  386. 

Maxillarg  sinus,  enlargement  of,  662. 
Measles,  02ihthalniia  from,  70. 
Measure,  linear,  of  sq\iint,  555. 
Medullary,  carcinoma  of  choroid,  448. 
of  orbit,  650. 

Meibomian  follicles,  obstruction  of,  682. 

glands,  inflammation  of,  675. 

Meissner,  on  neuro-paralytic  ophthalmia, 

103. 
Melanotic  cancer  of  choroid,  448. 

cancer  of  orbit,  653. 

Meningitis,  a  cause  of  amaurosis,  401. 

cerebro-sinnal,  cause  of  panophthal- 

mitis, 436. 
Meridian,    vertical,    of    eye,   action    of 

several  miiscles  on,  548. 
Mesoropter,  muscvdar,  553. 
Metamor2:)hopsia,  336,  35(i. 
Meyer,  Dr.,  on  division  of  ciliary  nerves 

in  sympathetic  ophthalmia,  205. 
Micropsia,  335. 
Military  ophthalmia,  28. 


INDEX. 


737 


Milium,  682. 

Molluscum  of  cjelids,  682. 

Mooren,  Dr.,  on  cataract,  218. 

on  fliplitlicritic  coujmictivitis,  44. 

on  li_vpcr;cstlicsia  of  retina,  367. 

on  telangiectasis  of  iris,  168. 

Moifhia,  snbcutaneons  injection  of,  in 

poisoning  by  atropine,  157. 
Moss,  Mr.,  on  purulent  oplitlialniia,  33. 
Mucocele,  617. 
Mailer,    Prof.    Heinricb,    on     capsular 

cataract,  227. 

on  colloid  disease  of  choroid,  439. 

on     orbital     imstriped     muscular 

fibres,  560 — note. 

on  retinitis  albuniinurica,  340. 

on  retinitis  pigmentosa,  351. 

3Ii(scce  Tolitantes,  318. 

Muscles  of  the  eye,  affections  of,  54'8. 

action  of,  548. 

paralysis  of,  553. 

Muscle-plane,  540. 
Muscular  asthenopia,  600. 
Mydriasis,  160. 
Myocephalon,  26. 
Mi/odesopia,  318. 
Myopia,  499,  506. 

ophthalmoscopic  diagnosis  of,  509. 

Myosin,  164. 


N. 


Ncevus  matemus  of  eyelids,  686. 
Nagel,  Dr.,  on  retinitis,  334. 
Nasal  duct,  exploration  of,  619. 

stricture  of,  618. 

treatment  of  stricture  of,  619. 

Near  2}oint,  503. 

Near  sic/htedness,  506. 
Nebula  of  cornea,  122. 
Necrosis  of  orbit,  632. 
Negation,   active,   of   retinal    image    in 
strabismus,  413,  575. 

passive,  of  retinal  image  in  cataract, 

230,  413. 
Negative  accommodation,  502. 
Nepihritic  retinitis,  336. 
Neuritis,  optic,  375. 

Neuro-paralytic  affection  of  cornea,  102. 
Neurosis,  sympathetic,  195. 
Nictitation,  691. 
Night-blindness,  416. 
Nitrate  of  sUvcr,  action  of  on  conjunctiva, 

35. 
Nunneley,  Mr.,  on  vascular  protrusion  of 

eyeball,  657. 
Nystagmus,  569. 


Oblique  illumiuation,  2. 
muscles,  origin  of,  550. 


Oblique  muscles,  functions  of,  551. 
Obliteration  of  lachrymal  sac,  624. 

of  pupil,  147. 

Ocular  sheath,  587. 

intlanamation  of,  633. 

CEdema  of  conjunctiva,  18,  24. 

of  eyelids,  668. 

of  retina,  330. 

Onyx,  98. 

Opacities  of  cornea,  122. 

of  lens,  215. 

of  vitreous,  315. 

Oplitlialniia,  Catari'hal,  16. 

diphtheritic,  40. 

Egyptian,  22. 

exauthematous,  70. 

gonorrhceal,  36. 

granular,  45. 

membranous,  24. 

military,  22. 

neonatoriun,  38. 

neuroparalytic,  102. 

phlyctenular,  64. 

pm'ulent,  22. 

sympathetic,  194. 

tarsi,  674. 

OpldJiahnoscope,  mode  of  using,  298. 

binocular,  of  Giraud-Teidon,  294. 

of  Laiu'ence  and  Heisch,  296. 

of  C'occins,  291. 

of  Helmholtz,  287. 

of  Liebreich,  290. 

of  Zehender,  292. 

fixed,  of  Liebreich,  293. 

. of  Smith  and  Beck,  294. 

Ophthalmoscopic  appearances  of  healthy 

eyes,  304. 
0]}tic  axis,  494,  496. 

disc,  normal,  ophthahnoscopic  ap- 

pearances of,  306. 

nerve,  diseases  of,  375. 

atrophy  of,  385. 

consecutive  atrophy  of,  387. 

simple  progressive  ati'ophy  of, 

386. 
in  cerebral  amaurosis,  400. 

• condition  of  in  tobacco  amau- 

rosis, 387. 

discoloration  of,  386 — note. 

excavation  or  cupping  of,  388. 

of  from  atrophy,  389. 

congenital  excavation  of,  388. 

glaucomatous  excavation  of, 

390. 

fibres,  opaque,  393. 

inflammation  of,  375. 

pigmentation  of,  392. 

tumoiu's  of,  393. 

Optic  neuritis,  375. 

ascending,  376. 

descending,  376. 

retro-ocular,  384. 

Optometer  of  Yon  Graefe,  506. 

of  Javal,  530. 

3  B 


738 


INDEX. 


Orbicularis  palpebrarum,  palsy  of,  689. 

spasm  of,  690. 

Orbit,  diseases  of,  627- 

abscess  of,  627. 

aneurisms  of,  654. 

diffuse  or  false  aneurism  of,  655. 

true  aneurism  of,  655. 

caries  of,  632, 

ceUulitis  of,  627. 

empbysema  of,  660. 

exostosis  of,  643. 

fractures  of,  66i. 

lisemorrbage  into,  659. 

hydatids  in,  646 . 

inflammation  of  cellular  tissue  of, 

627. 

injuries  of,  662. 

necrosis  of,  632. 

periostitis  of,  630. 

pressure  upon,  from  neigbbouring 

cavities,  660. 

wounds  of,  662. 

tumoiu's  of,  638. 

cartilagiueous,  643. 

cavernous,  653. 

cystic,  645. 

erectile,  654. 

fattv,  643. 

fibrous,  639. 

. osseous,  643. 

sarcomatous      (fibro-plastic), 

640. 
vascular,  653. 

cancer  of,  647. 

epithelial,  653. 

medullary,  650. 

melanotic,  653. 

scirrhus,  648. 

Orthoscopic  spectacles  of  Dr.  Scheffler, 

545. 
Oscillation  of  eyeballs,  569. 


Pagenstecher,  Dr.,  on  extraction  of  cata- 
ract, 251. 

on  operation  for  entropivun,  701. 

on  yellow  oxide  of  mercury  oint- 

ment, 68. 
Fannus,  89. 

from  granulations,  56,  90. 

hei'peticus,  65,  91. 

traumatic,  55. 

Panophthalmitis,  434. 
Pantoscopic  spectacles,  544. 
Paracentesis  cornese,  100,  113. 
Paralysis  of  muscles  of  the  eye,  553. 

of  fourth  nerve,  563. 

■  of  sixth  nerve,  553. 

of  third  nerve,  559. 

of  portio   dura   of  seventh   nerve, 

689. 


Paralysis  of  the  levator  palbebrse  supe- 
rioris,  687. 

of    the    orbicularis    palpebrarum, 

689. 

Perforation  of  cornea,  111. 

Periostitis  of  orbit,  630. 

Perisco2}ic  spectacles,  544. 

Peritomy,  61. 

Perivascular  retinitis,  334. 

Phlegmonous  inflammation  of  eyelids, 
669. 

Phlyctenular  ophthalmia,  64. 

Phlyctenulce  of  cornea,  91. 

Phosphenes,  493. 

Photophohia,  69. 

Phiheiriasis  of  the  eyelashes,  678. 

Phthisis  oculi,  188. 

Pinguecula,  84. 

Piringer,  on  contagiousness  of  conjuncti- 
val discharge,  28. 

Polycoria,  171. 

Polyopia,  monocvdar,  528. 

Polypi  of  lachrymal  sac,  626. 

Pope,  Dr.,  on  retinitis  pigmentosa,  351. 

Prael,  Dr.,  on  exophthalmic  goitre,  634. 

Presbyopia,  515. 

Pressure,  iutraocidar,  2,  459. 

bandage,  13. 

Prisms,  the  action  of,  10. 

in  muscular  asthenopia,  602. 

in  strabismus,  584. 

Prismatic  spectacles,  544. 
Probes,  lachrymal,  619. 

laminaria,  621. 

Prolapse  of  iris,  115,  244. 
Prothesis  ocuU,  666. 
Protrusion  of  globe,  634,  638. 
Pterygium,  73. 

Ptosis,  687. 

Puncta  lacrymalia,  610. 

eversion  of,  610. 

malposition  of,  610. 

obliteration  of,  612. 

obstruction  of,  612. 
Punctum  proximum,  503. 

remotissimum,  503. 

Pupil,  artificial,  operations  for,  172. 

by  incision,  180. 

by  ii'idectomy,  172. 

by  iridodesis,  178. 

by  iridodialysis,  181. 

dilatation  of,  160. 

adhesions  of,  147. 

contraction  of,  164. 

exclusion  of,  147. 

occlusion  of,  147. 

action  of  atropine  on,  161. 

action  of  Calabar  bean  on,  162. 

Pupillary  membrane,  persistence  of,  171. 
Pupillometer,  Mr.  Laurence's,  161. 
Purulent  ophthalmia,  22. 

Pustular  ophthalmia,  64. 
Pustule,  malignant  of  eyelid,  672. 


INDEX. 


739 


Q. 

Quinine,  amblyopia  from  cxcessire  use 
of,  412. 


R. 


Range  of  accommodation,  503. 

absolute,  503. 

binocular,  505. 

relative,  505. 

negative,  506. 

positive,  505. 

Re-adjusfment,  operation  of,  569,  598. 

Critchett's,  599. 

Ton  Graefe's  598. 

Liebreich's,  599. 

Reclination  of  cataract,  265. 
Recti  muscles,  fnnctious  of,  551. 

origin  of,  550. 

insufficiency  of  internal,  600. 
Rectus    mxiscle,    paralysis    of    external, 
553. 

of  inferior,  562. 

of  internal,  560. 

of  superior,  561. 
Refraction  of  the  eye,  488,  498. 

diseases  of,  498. 

diflerent  in  the  two  eyes,  546. 

Refracting  media,    ophthalmoscopic   ex- 
amination of,  310. 

Retina,  diseases  of,  327. 

anaesthesia  of,  418. 

aneurism  of  central  artery  of,  655. 

atrophy  of,  374. 

detachment  of,  353. 

emboUsm  of  central  artery  of,  363. 

epilepsy  of,  361. 

glioma 'of,  367. 

hypersemia  of,  327. 

hypersesthesia  of,  366. 

inflammation  of,  329. 

ischsemia  of,  362. 

operation  upon  the,  in  detachment 

of  retina,  359. 

paralysis  of,  414. 

tumours  of,  367. 

Retinitis,  329. 

albuminiu-ica  (nephi-itic)  336. 

apoplectica,  347. 

central  reciu-rent,  346. 

idiopatliic,  329. 

leucsemic,  343. 

parenchymatous,  331. 

perivascular,  334. 

pigmentosa,  319. 

serous,  329. 

syphihtic,  343. 

Retro-ocular  neuritis,  384. 
Rheumatic  iriti-*,  151. 

Robertson,  Dr.  Argyle,  on  Calabar  bean, 

540. 
Romberg,  Prof.,  on  blepharospasm.  691. 


Rothmund,  Dr.,  on  subconjunctival  injec- 
tion of  salt  and  water  in  corneal 
opacities,  126. 

Rupture  of  the  choroid,  451. 


s. 


Sac,  lachrymal,  diseases  of,  613. 

destruction  of,  624. 

Saemisch,  Dr.,  on  foreign  bodies  in  ante- 
rior chamber,  183. 
Sarcoma  of  choroid,  443. 
of  ciliary  body,  448. 

of  orbit,  610. 

Scalping  the  eyelids,  695. 
Scarlatina,  ophthalmia  in,  70. 
Scheffler,  Dr.,  on  spectacles,  545. 
Schidtze,  Prof  Max.,   on  colour  blind- 
ness, 419. 

Schiff,  Dr.,  on  ueuvo-paralytic  ophthal- 
mia, 104. 
Schweigger,  Prof.,  on  astigmatism,  532. 

on  capsidar  cataract,  227. 

on  glioma  retinaj,  370. 

on  retinitis  albumiuurica,  339. 

on  retinitis  pigmentosa,  350. 

on  stajihyloma  posticiim,  431. 

Scirrhus  of  orbit,  648. 

Sclerotic,  diseases  of,  209. 

injm'ies  and  wounds  of,  213. 

Sclerectasia  posterior,  427. 
Sclerotico-choroiditis  posterior,  427. 
Scoop  extraction,  255. 
Scotomata,  399,  406. 

Sebaceous  cysts  of  eyelids,  683. 

Secondary  cataract,  274. 

Seeley,  Dr.,  on  use  of  style,  623. 

Seton  in  corneitis,  97,  114. 

Sheath,  ocular,  587. 

Shields,  glass,  in  symblepharou,  78. 

Short-sightedness,  506. 

Sinus,  frontal,  diseases  of,  660. 

abscess  of,  661. 

Slitting  up  of  the  punctum,  610. 
Small-pox,  ophthalmia  in,  70. 
Snellen,  Dr.,  test-types  of,  4. 

on  neuro-paralytic  ophthalmia,  103. 

Snoiv  blindness,  418. 

Solution  of  cataract,  265. 

Soils,  Dr.,  on  aneurism  of  central  artery 

of  retina,  655. 
Spasm  of  the  ocular  muscles,  569. 

of  the  eyehds,  690. 

Specks  of  cornea,  122. 
Spectacles,  512. 

curved  blue,  545. 

dcccntred,  544. 

decentred  of  Giraud-Teulon,  5  1 1. 

mica.  Dr.  Cohn's,  546. 

orthosc^pic,  of  Scheffler,  545. 

pantoscopic,  544. 

periscopic,  544. 

prismatic,  544. 

3  B  2 


740 


INDEX. 


Spevtacles,  stenopaic,  in  corneal  opaci- 
ties, 127. 

in  different  refraction  of  the  two 

eyes,  546. 

Sperino,  Dr-,  on  paracentesis  of  cornea 
as  a  cure  for  cataract,  etc.,  273. 

Spinal  cord,  diseases  of,  a  cause  of  amau- 
rosis, 403. 

Squint,  vide  Strabismus. 

Staphyloma,  111. 

of  cornea  and  iris,  134. 

treatment  of,  134—140. 

Borelli's  operation  for,  140. 

Critchett's  operation  for,  137. 

operation  by  excision,  136. 

Graefe's  operation  for,  139. 

anterior  sclerotic,  210. 

posterior,  427. 

racemosum,  112. 

Stauunff's  papille,  376. 
SteinheiVs  glass  cone,  513. 

Stellwag  von  Carion  on  granulations,  45. 

Stillicldium  lacrymarum,  609. 

Stilling,  Dr.,  operation  of,  for  stricture 

of  lachi'ymal  passages,  622. 
Strabismometer  of  Mr.  Laurence,  555. 
Strabismus,  571. 

active  negation  of  retinal  image  in, 

575. 

primary  deviation  iu,  554. 

secondary  deviation  in,  554. 

linear  measurement  of,  555. 

alternans,  575. 

apparent,  524,  578. 

coucomitans,  572. 

convergent,  579. 

in  hypermetropia,  523,  580. 

in  myopia,  582. 

divergent,  582. 

in  myopia,  582. 

inonolateral,  575. 

paralytic,  554,  558. 

periodic,  580. 

treatment  of,  584. 

orthopaedic  treatment  of,  584. 

Javal's   orthopiEdic   treatment   of, 

585. 

treatment  of,  by  operation,  585. 

Critchett's  operation  for,  593. 

Von  Graefe's  operation  for,  587. 

Liebreich's  operation  for,  594. 

paralytic,  operation  for,  598. 

periodic,  operation  for,  596. 

secondary,  operation  for,  598. 

Streatfeild,  Mr.,  on  corelysis,  180. 

on  entropium,  702. 

on  operation  for  obliterated  jDuncta, 

612. 
■  Stricture  of  lachrymal  passages,  618. 

of  nasal  duct,  618. 

Stromei/er,  Dr.,  on  granular  ophthalmia, 

■  47. 
Sft/e  on  the  lids,  679. 
Style,  lachrymal,  623. 


Suction  syringe  for  cataract,  use  of,  272 
—  Mr.  Bowman's,  272. 

instrument,  Mr.  Tcale's,  272. 

Supra-orbital  nerve,  division  of,  in  ble- 
pharospasm, 691. 

Suture,  conjunctival,  in  strabismus  opera- 
tion, 591. 
Symhlepharon,  77. 

operations  for,  78. 

Arlt's  operation  for,  79. 

Teale's  operation  for,  79. 

Sympathetic  ophthalmia,  194. 
— —  choroid  o-retinitis,  197. 
— —  irido-cyclitis,  195. 

serous  iritis,  197. 

■  neurosis,  195. 

Synchysis,  320. 

sparkling,  321. 

Syndectomy,  61. 
Synechia,  147. 

annidar,  147. 

anterior,  111. 

— —  posterior,  147. 
Syndectomy,  61. 
Syphilitic  choroiditis,  423. 

corneitis,  117. 

u'itis,  150. 

retinitis,  343. 

ulcers  of  conjunctiva,  87. 

ulcers  of  eyelids,  673. 

Syringe  for  lachrymal  apparatus,  616. 

suction,   for  removal   of  cataract, 

272. 
SzokalsM  on  orbital  aneurism,  658. 


T. 


Tarsal  cysts,  681. 

ophthalmia,  674. 

Tarsoraphia,  706. 

Taylor,  Dr.,  on  cataract,  263. 
Teale,  Mr.  Pridgin,  on  removal  of  cata- 
ract by  suction,  272. 

on  cysticercus  in  anterior  chamber, 

184. 

on  mercury  and  atropine  in  iritis, 

158. 

on  method  of  examining  tlie  field 

of  vision,  8. 

on  operation  for  symhlepharon,  79. 

Telangiectasis  of  iris,  168. 

of  eyelids,  686. 

Tenon,  capsule  of,  587. 

inflammation  of  capsule  of,  633. 

Tenonitis,  633. 

Tension,  intra-ocular,  mode  of  estimat- 
ing, 2. 

in  glaucoma,  459. 

in  detached  retiua,  358. 

iu  intra-ocular  tumours,  369, 

445. 

Tenotomy  for  strabismus,  585. 

Third  nerve,  paralysis  of,  559. 


INDEX. 


741 


Tinea  tarsi,  674. 
Tobacco  amaurosis,  411. 
Trachoma,  5i. 
Transplantation  of  eilia,  696. 

operation  of,  for  restoration  of  eye- 

lid, 710. 
Traumatic  cataract,  226,  270. 
Tremulous  ii'is,  165. 
Trichiasis,  692. 
Truss,    Mr.    Critchett's,   for   lachrymal 

sac,  623. 
Tubercles  of  the  choroid,  440. 
Tumours,  cerebral,  a  cause  of  amaurosis, 

402. 

of  clioroid,  443. 

of  conjunctiva,  83. 

of  cornea,  143. 

of  eyelids,  681. 

of  ii-is,  167. 

of  optic  nerve,  393. 

of  orbit,  638. 

of  retina,  367. 

Turpentine,  iise  of,  in  iritis,  159. 
Twitching  of  eyelids,  691. 
Tylosis,  674. 


u. 

Ulcers  of  cornea,  108. 

syphilitic,  of  eyelids,  672. 

Unguis,  98. 


V. 


Vanzetti,  Dr.,  on  orbital  anem-ism,  658. 

Variolous  ophthalmia,  70. 

Venous  pulsation  of  central  vessels  of  the 

retina,  308. 
Vernon,  Mr.,  on  tubercle  of  choroid,  442. 
Vesicular  granvdations,  46. 
Vessels,  conjunctival,  17 — note. 

sclerotic,  17. 

subconjunctival,  17. 

Virchoto,  Prof.,  on  exophthalmic  goitre, 
634. 

on  glioma  of  the  retina,  368,  370. 

on  sarcoma  of  choroid,  446. 

on  sarcoma  of  orbit,  641. 

Visual  angle,  496. 

line,  494,  496 

Vision,  binocular,  mode  of  examination 
of,  576. 

in  strabismus,  575. 

— —  field  of,  mode  of  examination  of, 

5. 
Vitreous  humour,  diseases  of,  313. 

cholesterine   crystals  in,  321. 

cysticercus  in,  323. 

fluid  condition  of,  320. 

foreign  bodies,  in,  321. 

hsemorrhage  into,  316. 

inflammation  of,  313. 


Vitreous  humoiu's,  neo-plastic  formations 
in,  326. 

new  blood-vessels  in,  326. 

opacities  of,  315. 


w. 

Walton,   Mr.    Haynes,   on   exostosis   of 

orbit,  645. 
Warlomont,  Dr.,  on  chi-omhydrosis,  679. 

on  Stilling' s  operation,  622. 

Warts  on  conjunctiva,  85. 

on  eyelids,  684. 

Watery  eye,  609. 

Watson,  Mr.  Spencer,  on  setons  in  cor- 

neitis,  114 — note. 
Weakness  of  sight  (asthenopia),  522. 
Weher,  Dr.,  on  abscess  of  cornea,  99. 

canaliculus  knife  of,  620. 

on  corelysis,  180. 

graduated  lachrymal  sound  of,  620. 

on  persistence  of  pupillary  mem- 

brane, 171. 
WecJcer,  Dr.  on  fistula  of  cornea,  117. 

on   method   of    examining    visual 

field,  8. 

on  foreign  bodies  in  anterior  cham- 

ber, 183. 

on  removing  lens  in   its   capsule, 

251. 

on  myoma  of  choroid,  449. 

ointment  of,  for  tinea  tarsi,  677. 

on  detached  retina,  361. 

Wedl,  Prof,  on  colloid  disease  of  cho- 
roid, 439. 

Wegner,  Dr.,  on  glaucoma,  476. 

Welz,  von.  Dr.,  on  simulation  of  amau- 
rosis, 420. 

Wordsivorth,  Mr.,  on  glass  sliields  in 
symblepharon,  79. 

on  tobacco  amam-osis,  411. 

Wounds  of  cornea,  140. 

of  eyelids,  714. 

of  iris,  165. 

of  lens,  226. 

of  orbit,  662. 

of  sclerotic,  213. 


X. 


Xerophthalmia,  72. 


z. 

Zehender,  Prof.,  ophthalmoscope  of,  292. 

on  fistula  of  cornea,  117. 

on  orbital  tumom-s,  640. 

Zinc,  chloride   of  paste,    in  orbital   tu- 
mours, 642. 


^  ^^^^c^^o^i^i^>^ ^ 


LONDON 
HAERISON   AND  SONS,   PKINXERS  IN  OBDINABY   TO   HER  MAJESTY,   ST.   MABTIN's  LANE. 


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